A postoperative patient is diagnosed with ﬂuid volume overload. What should the nurse expect to assess in this patient?

Concentrated hemoglobin and hematocrit levels

Distended neck veins

Decreased urine output

Poor skin turgor

Answer and Explanation

The Correct Answer is B

Choice A: Concentrated hemoglobin and hematocrit levels are not a sign of ﬂuid volume overload, but rather of ﬂuid volume deficit. This is a condition that occurs when the body loses more ﬂuid than it gains. This can happen in patients who have excessive bleeding, vomiting, diarrhea, or diaphoresis. Concentrated hemoglobin and hematocrit levels indicate hemoconcentration, which is an increase in the ratio of blood cells to plasma.

Choice B: Distended neck veins are a sign of ﬂuid volume overload, because this condition occurs when the body retains more ﬂuid than it excretes. This can happen in patients who have heart failure, kidney failure, or excessive ﬂuid intake. Distended neck veins indicate increased central venous pressure, which is a measure of the pressure in the right atrium of the heart.

Choice C: Decreased urine output is not a sign of ﬂuid volume overload, but rather of oliguria or anuria. These are conditions that occur when the urine output is less than 400 mL or 50 mL per day, respectively. These can happen in patients who have acute or chronic kidney injury, urinary obstruction, or shock. Decreased urine output indicates impaired renal function and decreased glomerular filtration rate.

Choice D: Poor skin turgor is not a sign of ﬂuid volume overload, but rather of dehydration. This is a condition that occurs when the body loses more water than it gains. This can happen in patients who have fever, diabetes insipidus, or hyperglycemia. Poor skin turgor indicates decreased skin elasticity and delayed return to normal shape after being pinched.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A: Kussmaul respirations are a sign of metabolic acidosis, which is a condition that occurs when the body produces too much acid or loses too much bicarbonate. This can happen in patients with diabetes mellitus who develop diabetic ketoacidosis (DKA), a serious complication that results from insufficient insulin and high blood glucose levels. Kussmaul respirations are deep, rapid, and labored breathing that helps to eliminate excess carbon dioxide and acid from the blood.

Choice B: Cold, clammy skin is not a sign of metabolic acidosis, but rather of hypoglycemia, which is a condition that occurs when the blood glucose level is too low. This can happen in patients with diabetes mellitus who take too much insulin or oral hypoglycemic agents, skip meals, or exercise excessively. Cold, clammy skin is caused by vasoconstriction and sweating that occur as the body tries to increase blood glucose levels.

Choice C: Dysrhythmias are a sign of metabolic acidosis, because acidosis aﬀects the electrical activity of the heart and can cause irregular heartbeats. Dysrhythmias can also result from electrolyte imbalances, such as hyperkalemia, which is a condition that occurs when the blood potassium level is too high. This can happen in patients with metabolic acidosis who have impaired renal function and cannot excrete excess potassium.

Choice D: Tachycardia is a sign of metabolic acidosis, because acidosis stimulates the sympathetic nervous system and increases the heart rate. Tachycardia can also result from dehydration, which is a common complication of DKA due to excessive ﬂuid loss from vomiting, diarrhea, and polyuria.

Choice E: Weakness is a sign of metabolic acidosis because acidosis reduces the availability of oxygen and nutrients to the tissues and muscles. Weakness can also result from hypovolemia, which is a condition that occurs when the blood volume is too low. This can happen in patients with metabolic acidosis who have severe ﬂuid loss and hypotension.

A. Use an infusion controller for the IV. B. Add the ordered dose to the IV bag hanging. C. Monitor the injection site for redness. D. Monitor ﬂuid intake and output. E. Administer the dose IV push over 3 minutes.

Correct Answer is ["A","B","C"]

Explanation

Choice A Reason: This is correct because using an infusion controller for the IV ensures that the KCL is delivered at a safe and accurate rate. KCL can cause cardiac arrest if infused too rapidly or in excess.

Choice B Reason: This is correct because adding the ordered dose to the IV bag hanging dilutes the KCL and reduces the risk of phlebitis and extravasation. KCL is irritating to the veins and can cause tissue damage if it leaks out of the vein.

Choice C Reason: This is correct because monitoring the injection site for redness can help detect signs of phlebitis and extravasation. The nurse should stop the infusion and notify the provider if these complications occur.

Choice D Reason: This is incorrect because monitoring ﬂuid intake and output is not directly related to administering KCL. However, the nurse should monitor the patient's serum potassium level and renal function before and during KCL therapy, as kidney impairment can cause hyperkalemia.

Choice E Reason: This is incorrect because administering the dose IV push over 3 minutes is dangerous and contraindicated. KCL should never be given by IV push, bolus, or undiluted, as it can cause fatal cardiac arrhythmias.

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A postoperative patient is diagnosed with ﬂuid volume overload. What should the nurse expect to assess in this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. Which intervention should the nurse expect to be prescribed to correct this problem?

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A nurse is reviewing the laboratory results of a client who has ﬂuid volume deficit. The nurse would expect which of the following findings?

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