At the end of shift, you are calculating intake and output on your pat lent who was admited for a non- emergent gall bladder removal. She is alert and oriented and able to recall the amount of ﬂuid she has drank all day. You can calculate the amount of IV ﬂuids administered. Her intake is 2500ml and her output is 1200ml from a catheter bag. You realize she is not excreting enough urine me for water she is taking in. What is the most appropriate next step to determine if she is retaining water?

Put a hat in the toilet to collect proper output.

Assess your patient’s lower extremities and lungs for ﬂuid retention.

Educate her on the importance of writing down all ﬂuids she is drinking.

Document the numbers anyway, there is a probable error with the intake number.

Answer and Explanation

The Correct Answer is B

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

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Correct Answer is A

Explanation

A. Respiratory acidosis.

COPD is a chronic lung disease that can lead to an accumulation of carbon dioxide (CO2) in the body. This can cause respiratory acidosis, a condition in which the blood pH is lower than normal due to an excess of CO2.

In respiratory acidosis, the partial pressure of carbon dioxide (PaCO2) in the blood is increased and the pH is decreased. The kidneys atempt to compensate for the acidosis by excreting more acid in the urine and retaining more bicarbonate, but this compensation is usually not enough to fully correct the problem.

Metabolic alkalosis (option B) is a condition in which the blood pH is higher than normal due to an excess of bicarbonate in the blood. This is usually caused by loss of acid from the body, such as through vomiting or use of diuretics.

Respiratory alkalosis (option C) is a condition in which the blood pH is higher than normal due to a decrease in PaCO2. This can be caused by hyperventilation, which leads to excessive elimination of CO2 from the lungs.

Metabolic acidosis (option D) is a condition in which the blood pH is lower than normal due to an excess of acid in the blood. This can be caused by a variety of factors, including kidney failure or lactic acidosis.

A. Daily intake and output recordings B. Daily weights C. Daily blood pressure and heart rate checks D. Daily CMP lab draw

Correct Answer is B

Explanation

Daily weights provide a reliable and accurate measure of ﬂuid balance in the body. An increase in weight can indicate ﬂuid retention and the need for further intervention. While daily intake and output recordings, blood pressure and heart rate checks, and CMP lab draws can also provide useful information, daily weights are the most eﬀective way to monitor for excess ﬂuid volume in this situation.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which arterial blood gas data does the nurse anticipate finding in this patient?

Correct Answer is A

Explanation

A patient with congestive heart failure is at risk of excess ﬂuid volume. Which intervention will best determine if the patient is beginning to have excess ﬂuid volume?

Correct Answer is B

Explanation

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

During a Cardiac Stress test, a patient complains of chest pain while running The chest pain subsides when he stops running and is relaxed. The patient is diagnosed with Stable angina and is given education by the nurse. He understands the lack of muscles is causing stable angina during exercise.

Patient MK is admited with Atrial Fibrillation an irregular heart rhythm. She is also complaining of muscle cramps to her legs and that she started a new diuretic last week. What lab value are you most likely to find on her Complete Metabolic Panel?

The nurse is caring for a client who requires IV ﬂuids. which IV ﬂuid type would be considered a hypertonic solution?

The nurse is working on a cardiac unit with several patients who have intravenous access lines. The nurse identifies the following are considered central venous catheters: (Select All That Apply)

JD has been admited after a large portion of his colon has been removed due to cancer Which statement by the patient demonstrates that he understands the function of the Gastrointestinal tract as related to ﬂuid and electrolyte balance.

A patient presents to the Emergency Room with swollen legs and shortness of breath. He tells you that he has a history of heart failure which causes the ﬂuid to build up m his legs and lungs. When you listen to his lung sounds you are most likely to hear which type of breathing sounds?

A client with renal disease requires IV ﬂuids. It is important for the nurse to: