Nokea
An adult client is brought into the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next?
- A. Continue to monitor client with another appointment.
- B. Be prepared to administer a lactated Ringer's IV.
- C. Be prepared to administer a sodium chloride IV.
- D. Consider sodium restriction with discontinuation of salt tablets.
Correct Answer: D
Rationale: The client's symptoms of feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy suggest hypernatremia. The client needs to be evaluated with serum blood tests soon; a later appointment will delay treatment. It is necessary to restrict sodium intake. Salt tablets and a sodium chloride IV will only worsen this condition. A Lactated Ringer's IV is a hypertonic IV and is not used with hypernatremia. A hypotonic solution IV may be a part of the treatment, but not along with the salt tablets.
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The client's lab values are sodium $166 \mathrm{mEq} / \mathrm{L}$, potassium $5.0 \mathrm{mEq} / \mathrm{L}$, chloride $115 \mathrm{mEq} / \mathrm{L}$, and bicarbonate $35 \mathrm{mEq} / \mathrm{L}$. What condition is this client likely to have, judging by anion gap?
- A. Metabolic acidosis
- B. Respiratory alkalosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: A
Rationale: The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds $16 \mathrm{mEq} / \mathrm{L}$ indicates metabolic acidosis. In this case, the anion gap is $(166+5)-(115+35)$, yielding $21 \mathrm{mEq} / \mathrm{L}$, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?
- A. Kidney and liver
- B. Heart and lungs
- C. Lungs and kidney
- D. Pancreas and stomach
Correct Answer: C
Rationale: The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving $\mathrm{CO}_2$ by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.
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 an older adult client in the home setting who is experiencing decreased thirst. Which type of fluid imbalance should the nurse anticipate?
- A. Dehydration
- B. Hypovolemia
- C. Hypervolemia
- D. Third spacing
Correct Answer: A
Rationale: The nurse should anticipate the presence of dehydration, which is the most common fluid imbalance in older adult clients that results from decreased thirst. Hypovolemia is a condition in which only the blood volume is low. Hypervolemia is when the intravascular fluid volume is too high. Third spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. It is associated with the loss of colloids.
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.