Nokea
A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?
- A. Slow heart rate
- B. Kidney stones and blood clots
- C. Imbalance in electrolytes
- D. Elevated central venous pressure (CVP)
Correct Answer: B
Rationale: Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated hematocrit levels and blood cell counts indicate hemoconcentration, which means a high ratio of blood components in relation to watery plasma. This increases the potential for blood clots and urinary stones. In hypovolemia, the heart rate tends to be high because the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte levels tend to remain normal because they are depleted in proportion to the water loss. CVP is usually below $4 \mathrm{~cm} \mathrm{H}_2 \mathrm{O}$.
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The nurse is caring for a client who has been diagnosed with chronic obstructive pulmonary disease (COPD) and is experiencing respiratory acidosis. The client asks what is making the acidotic state. What does the nurse identify as the result of the disease process that causes the fall in $\mathrm{pH}$ ?
- A. The lungs are unable to breathe in sufficient oxygen.
- B. The lungs are unable to exchange oxygen and carbon dioxide.
- C. The lungs have ineffective cilia from years of smoking.
- D. The lungs are not able to regulate carbonic acid levels.
Correct Answer: D
Rationale: In clients with chronic respiratory acidosis, the client's lungs are not able to regulate carbonic acid levels. The increase in carbonic acid leads to acidosis. In COPD, the client is able to breathe in oxygen, and gas exchange can occur, but the lungs' ability to remove the carbon dioxide from the system is limited. Although individuals with COPD frequently have a history of smoking, ineffective cilia is not the cause of the acidosis.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?
- A. Low heart rate
- B. Elevated blood pressure
- C. Rapid respiration
- D. Subnormal temperature
Correct Answer: B
Rationale: Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.
The nurse is reviewing lab work on a newly admitted client. Which diagnostic stud(ies) confirms the nursing problem statement of dehydration? Select all that apply.
- A. An elevated hematocrit level
- B. A low urine specific gravity
- C. Electrolyte imbalance
- D. Low protein level in the urine
- E. Absence of ketones in urine
Correct Answer: A,C
Rationale: Dehydration is a common primary or secondary diagnosis in health care. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.
The nurse is caring for four clients on a medical unit. Which client's laboratory reports does the nurse review first for an electrolyte imbalance?
- A. A 7-year-old with a fracture tibia
- B. A 65-year-old with a myocardial infarction
- C. A 52-year-old with diarrhea
- D. A 72-year-old with a total knee repair
Correct Answer: C
Rationale: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression?
- A. Decreased abdominal girth
- B. Increased level of consciousness
- C. Weight maintenance
- D. Pulse rate decrease
Correct Answer: A
Rationale: Third-spacing is the translocation of fluid from the intravascular to intercellular space to tissue compartment. Anasarca is the general edema in the organ cavities such as the abdomen. Monitoring the abdominal girth provides data on the localization of the fluid in the interstitial space. A decrease in girth, in particular, notes improvement. Level of consciousness is not affected unless shock occurs. Weight remains the same as there is a shifting in fluid; pulse rate could fluctuate according to fluid movement.