The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first?

Offer calcium-rich foods.

Administer diuretic.

Raise head of bed.

Increase fluids.

Answer and Explanation

The Correct Answer is C

A. Offer calcium-rich foods: While calcium is important for overall health, offering calcium-rich foods is not an immediate intervention for the symptoms of crackles and neck vein distention. These signs suggest fluid overload, which needs urgent management.

B. Administer diuretic: Administering a diuretic can help remove excess fluid, but the first priority is to ensure the patient’s airway and breathing are supported. Diuretics can be administered once the patient is positioned properly.

C. Raise head of bed: Raising the head of the bed improves ventilation and helps alleviate respiratory distress, which is crucial when crackles, indicative of fluid in the lungs, and neck vein distention, suggesting fluid overload are present. This will help reduce the work of breathing and ease the patient’s discomfort.

D. Increase fluids: Increasing fluids is not appropriate in this situation because the patient is showing signs of fluid overload, crackles and neck vein distention. Fluid restriction or removal is required, not additional fluid intake.

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Correct Answer is B

Explanation

A. Chemical buffer system: This system provides an immediate but short-term response to changes in pH by neutralizing excess acids or bases. It works quickly but does not provide the long-term regulation of pH that is needed for maintaining acid-base balance over time.

B. Renal system: The renal system is the slowest regulatory system, taking hours to days to respond. It regulates pH by excreting hydrogen ions (H+) and reabsorbing bicarbonate (HCO3-) in the kidneys, helping to maintain long-term pH balance in the extracellular fluid (ECF). This makes it the most effective system for sustained pH regulation.

C. Respiratory system: The respiratory system responds more quickly than the renal system but not as rapidly as the chemical buffer system. It regulates pH by adjusting the level of carbon dioxide (CO2) in the blood through changes in the rate and depth of breathing.

D. Endocrine system: The endocrine system plays a role in fluid and electrolyte balance but is not directly involved in regulating acid-base balance. It influences pH indirectly through hormones that affect kidney function, but it is not the primary system for pH regulation.

A. Intracellular B. Extracellular C. Intravascular D. Transcellular

Correct Answer is A

Explanation

A. Intracellular: The majority of the body's total water volume is contained within the intracellular compartment, which makes up about 2/3 total body water. Intracellular fluid is essential for cellular function, and any depletion here contributes significantly to dehydration.

B. Extracellular: While extracellular fluid (ECF) accounts for about one-third of total body water, it is not the compartment that holds the majority. ECF includes interstitial fluid, blood plasma, and lymph, but intracellular fluid still holds a larger proportion.

C. Intravascular: Intravascular fluid is a subset of extracellular fluid, specifically the fluid found within blood vessels. It makes up a smaller portion of total body water and is primarily involved in transporting nutrients and waste.

D. Transcellular: Transcellular fluid is a small compartment of extracellular fluid, including fluids such as cerebrospinal fluid, synovial fluid, and ocular fluid. It represents a very small fraction of total body water.

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The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The regulatory system of acid-base balance takes the longest time to respond, and regulates pH of extracellular (ECF) by eliminating hydrogen ions or bicarbonate in body fluids.

Correct Answer is B

Explanation

A patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in which compartment?

Correct Answer is A

Explanation

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