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Instructions:

Use this scenario for the next 4 questions.

Exhibits

Indicate which assessment findings correlate with the nursing problem you identified. (Select all that apply)

Watery diarrhea for 3 days.

Chronic kidney disease, which has been managed with diuretics and fluid restrictions.

Lung sounds are clear.

No nausea and vomiting.

History of hypertension.

Blood urea nitrogen (BUN).

Answer and Explanation

Correct Answer : A,B,E,F

Choice A reason:

Watery diarrhea for 3 days is a significant finding that correlates with fluid and electrolyte imbalances. Diarrhea leads to the loss of fluids and electrolytes, which can result in dehydration and electrolyte disturbances such as hypokalemia or hyperkalemia. In this case, the patient’s potassium level is elevated (5.6 mEq/L), which could be a result of the body’s attempt to compensate for the loss of other electrolytes. Diarrhea also contributes to the patient’s weakness and lightheadedness due to dehydration.

Choice B reason:

Chronic kidney disease, which has been managed with diuretics and fluid restrictions, is another critical factor. Chronic kidney disease (CKD) affects the body’s ability to regulate fluid and electrolytes. The use of diuretics can exacerbate electrolyte imbalances, particularly potassium levels. In this scenario, the patient’s elevated potassium level (5.6 mEq/L) is concerning, as CKD patients are at higher risk for hyperkalemia due to decreased renal excretion of potassium. The combination of CKD and recent diarrhea increases the complexity of managing the patient’s fluid and electrolyte balance.

Choice C reason:

Lung sounds are clear is an important assessment finding but does not directly correlate with the primary nursing problem of fluid and electrolyte imbalance. While clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection, this finding does not address the immediate concerns related to fluid loss and electrolyte disturbances. Therefore, it is not a priority in this context.

Choice D reason:

No nausea and vomiting is a relevant finding but does not directly correlate with the primary nursing problem. The absence of nausea and vomiting is positive, as it indicates that the patient is not losing additional fluids and electrolytes through emesis. However, it does not address the significant fluid loss from diarrhea or the electrolyte imbalances that are the primary concerns in this scenario.

Choice E reason:

History of hypertension is a relevant factor in the patient’s overall health status. Hypertension can complicate the management of fluid and electrolyte imbalances, particularly in patients with CKD. The use of antihypertensive medications and diuretics can affect electrolyte levels and fluid balance. In this case, the patient’s blood pressure is slightly low (109/70), which could be related to dehydration from diarrhea and the effects of antihypertensive medications. This history is important for understanding the patient’s baseline and potential complications.

Choice F reason:

Blood urea nitrogen (BUN) is elevated at 30 mg/dL, which is above the normal range (6-24 mg/dL). An elevated BUN level indicates impaired kidney function and can be a sign of dehydration or renal insufficiency. In the context of CKD and recent diarrhea, an elevated BUN suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions.

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Correct Answer is C

Explanation

Choice A: Hypotonic

A hypotonic solution has a lower concentration of solutes compared to the fluid inside the cells. When cells are placed in a hypotonic solution, water enters the cells, causing them to swell and potentially burst. This is because the osmotic pressure drives water into the cells to balance the solute concentration. Hypotonic solutions are not used to describe a state where extracellular and intracellular fluids have the same osmolality.

Choice B: Oncotic Pressure

Oncotic pressure, also known as colloid osmotic pressure, is the form of osmotic pressure exerted by proteins, primarily albumin, in the blood plasma. It plays a crucial role in maintaining fluid balance between the blood vessels and the surrounding tissues by pulling water into the circulatory system. Oncotic pressure is not related to the concept of equal osmolality between extracellular and intracellular fluids.

Choice C: Isotonic

An isotonic solution has the same concentration of solutes as the fluid inside the cells. When extracellular fluid is isotonic to intracellular fluid, there is no net movement of water into or out of the cells, maintaining cell stability. This balance is crucial for normal cellular function and is the term used to describe equal osmolality between extracellular and intracellular fluids.

Choice D: Hypertonic

A hypertonic solution has a higher concentration of solutes compared to the fluid inside the cells. When cells are placed in a hypertonic solution, water leaves the cells, causing them to shrink or crenate. This occurs because the osmotic pressure drives water out of the cells to balance the solute concentration. Hypertonic solutions are not used to describe a state where extracellular and intracellular fluids have the same osmolality.

A. Changing the patient’s position every 3 to 4 hours. B. Provide adequate and regular pain medication. C. Encourage deep breathing and coughing. D. Place the conscious patient in a supine position with the head of the bed elevated. E. Encourage bed rest for the first 4 hours after surgery.

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

Explanation

Choice A reason:

Changing the patient’s position every 3 to 4 hours is crucial to prevent complications such as pressure ulcers and deep vein thrombosis (DVT). Immobility can lead to the development of pressure ulcers, especially in patients who are bedridden or have limited mobility. Regular repositioning helps to alleviate pressure on vulnerable areas of the body, promoting better circulation and preventing skin breakdown. Additionally, changing positions can help in preventing DVT by encouraging blood flow and reducing the risk of blood clots forming in the legs.

Choice B reason:

Providing adequate and regular pain medication is essential for postoperative care to ensure patient comfort and facilitate recovery. Pain management is a critical aspect of postoperative care as unmanaged pain can lead to complications such as increased heart rate, hypertension, and delayed wound healing. Adequate pain control allows the patient to participate in necessary activities such as deep breathing exercises and ambulation, which are vital for preventing complications like pneumonia and promoting overall recovery. Pain medication should be administered as prescribed, and the patient’s pain levels should be regularly assessed and documented.

Choice C reason:

Encouraging deep breathing and coughing is vital for preventing respiratory complications such as atelectasis and pneumonia. After surgery, patients are at risk of developing these complications due to the effects of anesthesia and prolonged immobility. Deep breathing exercises help to expand the lungs fully, improving oxygenation and preventing the collapse of alveoli. Coughing helps to clear secretions from the airways, reducing the risk of infection. Nurses should instruct patients on how to perform these exercises effectively and encourage them to do so regularly.

Choice D reason:

Placing the conscious patient in a supine position with the head of the bed elevated is important for maintaining airway patency and promoting optimal respiratory function. Elevating the head of the bed helps to reduce the risk of aspiration and improves lung expansion, facilitating better breathing. This position is particularly beneficial for patients who may have residual effects of anesthesia or are at risk of respiratory complications. It also helps in reducing the workload on the heart and improving overall comfort.

Choice E reason:

Encouraging bed rest for the first 4 hours after surgery is generally not recommended as early mobilization is crucial for preventing complications such as DVT, pulmonary embolism, and muscle atrophy. While it is important to ensure that the patient is stable before encouraging movement, prolonged bed rest can lead to adverse outcomes. Instead, patients should be encouraged to engage in light activities as soon as they are able, under the supervision of healthcare professionals. This helps to promote circulation, improve respiratory function, and enhance overall recovery.

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Instructions: Use this scenario for the next 4 questions. Exhibits Indicate which assessment findings correlate with the nursing problem you identified. (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which term would the nurse use when extracellular fluid and intracellular fluid have the same osmolality?

Correct Answer is C

Explanation

The following 4 questions pertain to this case study: Exhibits Indicate which nursing interventions the post-surgical unit nurse should complete. (Select all that apply)

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

Explanation

Neutropenia increases the patient’s risk for life-threatening infection and sepsis.

A person with a blood pH of 7.21 is considered to have which of the following?

Which statement best describes the nurse’s role in medication reconciliation?

IV potassium chloride (KCl) 60 mEq is prescribed for a 49-year-old female patient with severe hypokalemia. Which action should the nurse take?

A 49-year-old female patient receives 3% NaCl solution for the correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?

The following 4 questions pertain to this case study: Exhibits Which task is appropriate for the nurse to delegate to experienced certified nurse assistant (CNA)?

A priority goal of the nursing pain assessment is to:

All patient teaching occurs in a formalized teaching session.

Instructions:

Use this scenario for the next 4 questions.

Exhibits

Indicate which assessment findings correlate with the nursing problem you identified. (Select all that apply)