The client is admitted to the nurse’s unit with a diagnosis of heart failure. His heart is not pumping effectively, resulting in edema and coarse crackles in his lungs. The term for this condition is?

Fluid volume deficit

Fluid volume excess

Myocardial infarction

Atelectasis

Answer and Explanation

The Correct Answer is B

Choice A reason: Fluid volume deficit, or hypovolemia, involves decreased fluid volume, causing symptoms like dehydration and hypotension. Heart failure leads to fluid retention due to poor cardiac output, resulting in edema and lung crackles, which are signs of fluid overload, not deficit, making this an incorrect diagnosis.

Choice B reason: Fluid volume excess, or hypervolemia, occurs in heart failure when the heart’s reduced pumping capacity causes fluid backup, leading to edema and pulmonary congestion (crackles). This matches the client’s symptoms, as ineffective cardiac output increases venous pressure, causing fluid to accumulate in tissues and lungs.

Choice C reason: Myocardial infarction is a heart attack caused by coronary artery occlusion, leading to myocardial ischemia. While it can cause heart failure, the client’s symptoms of edema and crackles specifically indicate fluid volume excess due to heart failure, not the acute event of infarction itself.

Choice D reason: Atelectasis is lung collapse due to airway obstruction or compression, causing reduced breath sounds, not crackles. Heart failure’s pulmonary edema causes coarse crackles due to fluid in alveoli. Atelectasis does not explain the client’s edema or fluid-related symptoms, making it an incorrect choice.

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Correct Answer is C

Explanation

Choice A reason: Hypocalcemia, or low blood calcium, results from impaired parathyroid function or vitamin D deficiency, causing muscle cramps and tetany. Laxative abuse primarily causes potassium loss through diarrhea, not calcium. Calcium homeostasis is tightly regulated, and laxative-induced diarrhea does not significantly deplete calcium, making this an unlikely cause of the client’s symptoms.

Choice B reason: Hyperkalemia, elevated blood potassium, occurs in conditions like renal failure or excessive potassium intake. Laxative abuse leads to potassium loss via frequent bowel movements, causing hypokalemia, not hyperkalemia. High potassium can cause cardiac arrhythmias, but the client’s fatigue and weakness align more closely with low potassium levels.

Choice C reason: Hypokalemia, low blood potassium, is a common consequence of laxative abuse due to excessive fecal potassium excretion. Potassium is essential for muscle and nerve function, and its depletion causes fatigue, weakness, and potential arrhythmias. The client’s symptoms of tiredness and weakness strongly indicate hypokalemia as the primary electrolyte imbalance.

Choice D reason: Hypernatremia, high blood sodium, results from dehydration or excessive sodium intake. While laxative abuse can cause dehydration, the primary electrolyte loss is potassium, not sodium retention. Hypernatremia may cause neurological symptoms like confusion, but the client’s fatigue and weakness are more characteristic of hypokalemia than hypernatremia.

A. Advance the catheter to the bifurcation or “Y” level of the ports B. Instruct the patient to contract or squeeze his pelvic muscles C. Bathe the catheter after urine appears in the tube prior to inflating the balloon D. Advance the catheter 2–3 inches after urine appears in the tube prior to inflating the balloon

Correct Answer is D

Explanation

Choice A reason: Advancing to the bifurcation ensures the balloon is in the bladder but risks over-insertion, potentially damaging the urethra. Proper technique involves advancing 2–3 inches after urine flow to confirm bladder placement, ensuring the balloon inflates safely without obstructing the urethra or causing trauma.

Choice B reason: Instructing pelvic muscle contraction is irrelevant during catheterization, as it does not aid insertion or balloon placement. Pelvic exercises may help post-catheterization for continence but are not part of insertion protocol. The focus is on correct catheter positioning to avoid complications like bladder trauma.

Choice C reason: Bathing the catheter after urine appears is unnecessary and not standard practice. Catheter insertion requires sterile technique, and cleaning occurs before insertion. Post-urine cleaning risks contamination or delay in securing the catheter, potentially causing displacement or infection, making this an incorrect step.

Choice D reason: Advancing the catheter 2–3 inches after urine appears ensures the balloon is fully in the bladder before inflation, preventing urethral trauma or balloon rupture. This standard technique confirms proper placement, as urine flow indicates the catheter tip has reached the bladder, ensuring safe and effective catheterization.

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The client is admitted to the nurse’s unit with a diagnosis of heart failure. His heart is not pumping effectively, resulting in edema and coarse crackles in his lungs. The term for this condition is?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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