KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to ﬁnd initially before ﬂuid balance reaches homeostasis?

Crackles to Bilateral lobes

Tenting skin and wet mucous membranes

C Tachycardia and hypotension

+4 edema to bilateral lower extremities and confusion

Answer and Explanation

The Correct Answer is C

Dehydration can cause a decrease in blood volume, leading to a drop in blood pressure (hypotension) and an increase in heart rate (tachycardia) as the body tries to compensate. Tenting skin and dry mucous membranes are also signs of dehydration, but wet mucous membranes are not. Crackles in the lungs, edema, and confusion can occur with ﬂuid overload, but not with dehydration.

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Correct Answer is D

Explanation

Explanation: The normal range of sodium (Na+) in the blood is 135-145 mEq/L. The patient's sodium level of 121 mEq/L is below the normal range, indicating a low sodium level, which is called hyponatremia.

Hyponatremia is a common electrolyte imbalance that can be caused by a variety of factors, including excessive sweating, vomiting, diarrhea, certain medications, kidney disease, and hormonal imbalances. It can cause symptoms such as nausea, headache, confusion, seizures, and coma, and it can be a medical emergency if the sodium level drops rapidly or severely.

A. Auscultate bilateral breath sounds. B. Obtain blood culture for tuberculosis. C. Request pulmonary function studies. D. Document the findings.

Correct Answer is A

Explanation

The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can aﬀect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.

While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.

Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.

Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.

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KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to ﬁnd initially before ﬂuid balance reaches homeostasis?

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Naxlex Comprehensive Predictor Exams

Your patient has a CMP drawn to determine their electrolytes. Only part of the values have resulted including the Na+ which is 121 mEq/l. What type of electrolyte imbalance is the patient having?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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