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A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?
- A. vital signs
- B. edema
- C. intake and output
- D. weight
Correct Answer: D
Rationale: Daily weight provides the ability to monitor fluid status. A 2-lb $(0.9 \mathrm{kg})$ weight gain in 24 hours indicates that the client is retaining $1 \mathrm{~L}$ of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output do not account for unexplainable fluid loss.
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The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?
- A. Similar causes are present in both conditions.
- B. Hypovolemia contains only low blood volume.
- C. In dehydration, only extracellular is depleted.
- D. Both conditions result in abnormal laboratory studies.
Correct Answer: C
Rationale: In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.
A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the correct answer from the nurse?
- A. Passive osmosis
- B. Free flow
- C. Passive elimination
- D. Active transport
Correct Answer: D
Rationale: Active transport is the physiologic pump that moves fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate for energy. Passive osmosis does not require energy for transport. Free flow is transport of water naturally. Passive elimination is a filter process carried out in the kidneys.
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 receives report that a client's $\mathrm{pH}$ level is 7.4. Which nursing action would be most appropriate?
- A. Call the health care provider with the report.
- B. Encourage the client to practice deep breathing.
- C. Finish the head-to-toe assessment.
- D. Obtain an ECG.
Correct Answer: C
Rationale: The nurse realizes that a $\mathrm{pH}$ level of 7.4 is within normal limits. No additional measures need obtained and the nurse would perform a usual head-to-toe assessment.