A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client
has dry oral mucous membranes, temperature 38.5° C
... [Show More] (101.3° F), pulse 92/min, respirations 24/min, skin
cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specific
gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select all that apply.)
A. Decreased skin turgor
B. Concentrated urine
C. Bradycardia
D. Low-grade fever
E. Tachypnea
A. CORRECT: Decreased skin turgor is a clinical manifestation present with fluid volume deficit. Skin
turgor is decreased to due to the lack of fluid within the body and results in dryness of the skin.
B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume deficit. The
urine is concentrated due to urinary output being decreased.
D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume deficit. Low-grade fever
is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body.
E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit. Increased
respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body.
A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain
of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature
37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal
cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative
of fluid volume excess? (Select all that apply.)
A. Dyspnea
B. Edema
C. Bradycardia
D. Hypertension
E. Weakness
A. CORRECT: Dyspnea is a clinical manifestation present with fluid volume excess. Dyspnea is due to
an excess of fluids within the body and lungs, and the client is struggling to breath to obtain oxygen.
B. CORRECT: Edema is a clinical manifestation present with fluid volume excess. Edema is due to the
excess of fluid within the body. Weight gain can be a result of edema.
D. CORRECT: Hypertension is a clinical manifestation related to fluid volume excess. Blood pressure
rises as the heart must work harder due to the excess fluid.
E. CORRECT: Weakness is a clinical manifestation present with fluid volume excess. Weakness is due
to the excess fluid that is retained, which depletes energy and increases the workload for the body.
A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should
the nurse assess for that is indicative of fluid volume deficit?
A. Moist skin
B. Distended neck veins
C. Increased urinary output
D. Tachycardia
D. CORRECT: Tachycardia is an attempt to maintain blood pressure, a clinical manifestation
indicative of fluid volume deficit.
A nurse is caring for an older adult client in a long-term care facility. The client has become weak and
confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's temperature is 38.3° C
(100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb
and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished
breath sounds in the right lower lobe. Which of the following actions should the nurse take?
A. Initiate fluid restrictions to limit intake.
B. Observe for signs of hypertension.
C. Encourage the client to ambulate to promote oxygenation.
D. Monitor respirations for shortness of breath.
D. CORRECT: It is an appropriate action for the nurse to monitor the client's respiratory status and for
shortness of breath. The client has a nonproductive cough with diminished breath sounds in the
right lower lobe. This client is dehydrated and has fluid volume deficit.
A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L.
Which of the following treatments can result in these laboratory findings?
A. Three tap water enemas
B. 0.9% sodium chloride solution IV at 50 mL/hr
C. 5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr
D. Administration of glucocorticoids
A. CORRECT: Receiving three tap water enemas can result in a decrease in serum sodium and
potassium in the client. Tap water is hypotonic, and gastrointestinal losses are isotonic. This
creates an imbalance and solute dilution.
A nurse is caring for a client who has a laboratory finding of serum potassium 5.4 mEq/L. The nurse
should assess for which of the following clinical manifestations?
A. ECG changes
B. Constipation
C. Polyuria
D. Hypotension
A. CORRECT: The nurse should assess the client for ECG changes. Potassium levels can affect the
heart and result in arrhythmias
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The
nurse should monitor for which of the following electrolyte imbalances?
A. Hypercalcemia
B. Hyponatremia
C. Hyperphosphatemia
D. Hypomagnesemia
B. CORRECT: The nurse should monitor the client for hyponatremia. Nasogastric losses are isotonic
and contain sodium.
A nurse is assessing a client for Chovstek's sign. Which of the following techniques should the nurse use
to perform this test?
A. Apply a blood pressure cuff to the client's arm.
B. Place the stethoscope bell over the client's carotid artery.
C. Tap lightly on the client's cheek.
D. Ask the client to lower his chin to his chest.
C. CORRECT: The nurse taps the client's cheek over the facial nerve just below and anterior to the ear
to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching
on this side of his face.
A nurse is assessing a client who has hyperkalemia. Which of the following conditions is associated with
this electrolyte imbalance?
A. Diabetic ketoacidosis
B. Heart failure
C. Cushing's syndrome
D. Thyroidectomy
A. CORRECT: Hyperkalemia, an increase in serum potassium, is a laboratory finding associated with
diabetic ketoacidosis.
A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal a blood pressure of 104/72 mm Hg, heart rate of 116 beats/min with a regular rhythm, and a respiratory rate of 42/min and deep. Which of the following arterial blood gases findings should the nurse expect?
A. pH 7.68, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 24 mEq/L
B. pH 7.48, PaO2 100 mm Hg, PaCO2 28 mm Hg, HCO3- 23 mEq/L
C. pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L
D. pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L
C. CORRECT: An aspirin overdose would result in arterial blood gas findings of metabolic acidosis.
A nurse is caring for a client who was in a motor-vehicle accident. He is reporting chest pain and
difficulty breathing. A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are
obtained. Which of the following findings should the nurse expect?
A. pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3- 24 mEq/L
B. pH 7.42, PaO2 100 mm Hg, PaCO2 38 mm Hg, HCO3- 23 mEq/L
C. pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L
D. pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L
A. CORRECT: A pneumothorax can cause alveolar hyperventilation and increased carbon dioxide
levels, resulting in a state of respiratory acidosis.
A nurse is admitting a client who has been vomiting for 24 hr. Arterial blood gases are obtained. Based
on the laboratory findings, which of the following conditions should the nurse expect?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
D. CORRECT: Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in
the blood, resulting in metabolic alkalosis.
A nurse is orienting a newly licensed nurse on conditions related to metabolic acidosis. Which of the
following statements by the new nurse indicates the teaching has been effective?
A. "Metabolic acidosis can occur due to diabetic ketoacidosis."
B. "Metabolic acidosis can occur in a client who has myasthenia gravis."
C. "Metabolic acidosis can occur in a client who has asthma."
D. "Metabolic acidosis can occur due to cancer."
A. CORRECT: Metabolic acidosis results from an excess production of hydrogen ions, which occurs in
diabetic ketoacidosis.
A nurse is assessing a client who has pancreatitis. His arterial blood gases reveal metabolic acidosis.
Which of the following is an expected finding? (Select all that apply.)
A. Tachycardia
B. Hypertension
C. Bounding pulses
D. Hyperreflexia
E. Dysrhythmia
F. Tachypnea
B. CORRECT: Hypotension is an expected finding of metabolic acidosis.
C. CORRECT: Weak peripheral pulses is an expected finding of metabolic acidosis.
D. CORRECT: Hyporeflexia is an expected finding of metabolic acidosis.
E. CORRECT: Dysrhythmia is an expected finding in a client who has pancreatitis and metabolic acidosis.
F. CORRECT: Tachypnea is an expected finding in a client who has pancreatitis and metabolic acidosis. [Show Less]