The nurse assesses a client admitted with a history of vomiting and diarrhea for 5 days. Which laboratory value validates the symptoms of the client?
Na+ 150 mEq/L
Cl-95 mEq/L
K+3.7 mEq/L
HCO3-26 mEq/L
The Correct Answer is A
A. The elevated serum sodium (Na+) level of 150 mEq/L validates the symptoms of vomiting and diarrhea in the client. Vomiting and diarrhea lead to fluid loss and dehydration, resulting in an increased serum sodium concentration due to the loss of water from the body. Hypernatremia (elevated serum sodium) is consistent with dehydration resulting from prolonged vomiting and diarrhea. An elevated sodium level is indicative of hypertonic dehydration, where water loss exceeds electrolyte loss, leading to increased serum sodium concentration
B. Cl-95 mEq/L: Chloride (Cl-) is an electrolyte often lost in cases of vomiting and diarrhea due to the loss of gastric secretions and chloride-rich fluids. A chloride level of 95 mEq/L is slightly lower than normal (normal range: 96-106 mEq/L), which suggests mild chloride depletion.
C. K+3.7 mEq/L: Potassium (K+) levels within the normal range (3.5-5.0 mEq/L) do not necessarily validate symptoms of vomiting and diarrhea. While potassium loss can occur in cases of prolonged vomiting and diarrhea, the potassium level provided falls within the normal range.
D. HCO3-26 mEq/L: Bicarbonate (HCO3-) levels within the normal range (22-29 mEq/L) do not necessarily validate symptoms of vomiting and diarrhea. Elevated bicarbonate levels may indicate metabolic alkalosis, which can occur as a compensatory mechanism in response to acid loss through vomiting or diarrhea, but this value alone does not confirm the symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Isotonic fluid helps the client feel less thirsty when they are NPO: While isotonic fluids can help maintain hydration status, they do not directly address the sensation of thirst. Isotonic fluids replace extracellular fluid volume and help maintain electrolyte balance but do not affect the sensation of thirst.
B. This type of IV hydration replaces blood volume without affecting intracellular fluid: This is the correct property of isotonic fluid replacement. Isotonic IV fluids have a similar osmolarity to extracellular fluid and thus replace fluid volume without significantly impacting the distribution of water between intra- and extracellular compartments. They are effective for expanding intravascular volume without causing a significant shift of water into or out of cells.
C. Isotonic IV hydration can cause cells to burst if given too rapidly: Isotonic IV fluids have the same osmotic pressure as blood plasma and therefore do not cause cells to burst when administered at appropriate rates. It is hypertonic solutions that can cause cells to shrink or swell due to osmotic imbalances.
D. This type of IV fluid must be given in an intensive care setting with frequent monitoring of the client's vital signs: While isotonic fluids are commonly used in various clinical settings, including intensive care, they do not inherently require administration in an intensive care setting with frequent monitoring of vital signs. Isotonic fluids are often administered in routine medical-surgical settings for various fluid balance problems.
Correct Answer is A
Explanation
A. Be available to the client: This is the most appropriate action for the nurse to take. The client's question reflects existential distress and a search for meaning in the face of suffering. Being available to listen to the client's concerns, offering emotional support, and providing a safe space for the client to express their feelings can be comforting and therapeutic. The nurse should demonstrate empathy, validate the client's emotions, and encourage open communication without imposing personal beliefs or judgments.
B. Call the physician for an antianxiety medication: While the client may be experiencing anxiety or distress, immediately resorting to medication is not the most appropriate response to the client's existential question. Antianxiety medication may provide temporary relief of symptoms but does not address the underlying spiritual or existential distress. It is essential for the nurse to explore the client's concerns and provide holistic support rather than solely relying on pharmacological interventions.
C. Advise the client to pray for answers: This response imposes the nurse's religious or spiritual beliefs onto the client and may not be appropriate for individuals who do not share the same beliefs. It is essential for the nurse to respect the client's autonomy and beliefs while providing support and guidance. Instead of advising the client to pray, the nurse should focus on active listening, empathy, and providing nonjudgmental support.
D. Share personal religious beliefs with the client: Sharing personal religious beliefs with the client is not appropriate in this situation. Doing so may impose the nurse's beliefs onto the client, which can be perceived as intrusive or insensitive. It is essential for the nurse to maintain professional boundaries and respect the client's autonomy, beliefs, and preferences. The focus should be on providing empathetic support and addressing the client's emotional and existential concerns.
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