The nurse is caring for a client being treated for fluid volume excess. Which assessment finding indicates that treatment has been effective?

Respiratory rate 24/min

Blood pressure 138/86 mm Hg

Total urinary output 700 mL in 24 hours

Weight loss of 4 lb in 24 hours

Answer and Explanation

The Correct Answer is D

A. Respiratory rate 24/min: A respiratory rate of 24/min indicates tachypnea, which can be a sign of ongoing fluid volume excess or other complications. This does not show effective treatment.
B. Blood pressure 138/86 mm Hg: While this blood pressure is within the higher range of normal, it does not specifically indicate effective treatment of fluid volume excess. Blood pressure alone is not a reliable indicator of fluid status.
C. Total urinary output 700 mL in 24 hours: A urinary output of 700 mL in 24 hours is below the normal range (typically 800-2000 mL per day) and suggests that the fluid volume excess has not been effectively treated. Adequate urinary output is a key indicator of effective fluid management.
D. Weight loss of 4 lb in 24 hours: A weight loss of 4 lb in 24 hours is a clear indicator that the client has lost excess fluid, which is the desired outcome in treating fluid volume excess. This demonstrates that the treatment has been effective in reducing fluid retention

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Correct Answer is B

Explanation

A. Hypercholesterolemia: This condition primarily affects cholesterol levels and is not directly associated with phosphorus imbalances. It does not typically cause hypophosphatemia.
B. Malnutrition: This is the correct choice. Malnutrition can lead to hypophosphatemia (low serum phosphorus levels) due to inadequate dietary intake of phosphorus and impaired absorption.
C. Renal insufficiency: Renal insufficiency generally causes hyperphosphatemia (high serum phosphorus levels) due to the kidneys' reduced ability to excrete phosphate, not hypophosphatemia.
D. Hypoparathyroidism: This condition is more commonly associated with hypocalcemia (low calcium levels) rather than hypophosphatemia. In some cases, hypoparathyroidism can cause elevated phosphorus levels, but not typically hypophosphatemia.

A. Respiratory acidosis without compensation B. Metabolic acidosis with full compensation C. Respiratory acidosis with partial compensation D. Metabolic acidosis without compensation

Correct Answer is C

Explanation

A. Respiratory acidosis without compensation: The pH of 7.22 indicates acidosis, but the HCO3 level of 23 mEq/L suggests that compensation is occurring because the HCO3 is within the normal range for respiratory acidosis.
B. Metabolic acidosis with full compensation: The high PaCO2 level is more indicative of respiratory issues, not metabolic acidosis. Additionally, compensation for metabolic acidosis would show elevated HCO3.
C. Respiratory acidosis with partial compensation: The elevated PaCO2 and low pH indicate respiratory acidosis. The normal HCO3 level suggests partial compensation by the kidneys.
D. Metabolic acidosis without compensation: The elevated PaCO2 and normal HCO3 suggest respiratory acidosis rather than metabolic acidosis.

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The nurse is caring for a client being treated for fluid volume excess. Which assessment finding indicates that treatment has been effective?

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Naxlex Comprehensive Predictor Exams

A nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level?

Correct Answer is B

Explanation

An unresponsive client was brought to the emergency room and had an arterial blood gas drawn. Ten minutes later, the laboratory calls with the following results: PaO2 74%, pH 7.22, PaCO2 85 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which imbalance?

Correct Answer is C

Explanation

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