Nokea
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.
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Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing?
- A. Initiate an IV of an isotonic solution.
- B. Initiate an IV of albumin.
- C. Manage an infusion of plasma.
- D. Manage an infusion of total parenteral nutrition.
Correct Answer: B
Rationale: The best answer to restore colloidal osmotic pressure is to initiate an IV of albumin. Administration of albumin pulls the trapped fluid back into the intravascular space. An isotonic solution will not pull water from the intercellular space. Blood products are used for third-spacing management; however, albumin is the product of choice. The management of total parenteral nutrition is not associated with third- spacing.
Upon shift report, the nurse states the following laboratory values: $\mathrm{pH}, 7.44 ; \mathrm{PCO}_2, 30 \mathrm{mmHg}$; and $\mathrm{HCO}_3, 21 \mathrm{mEq} / \mathrm{L}$ for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state?
- A. Compensated respiratory alkalosis
- B. Uncompensated respiratory alkalosis
- C. Compensated metabolic acidosis
- D. Compensated metabolic alkalosis
Correct Answer: A
Rationale: The question states that the client has a history of acid-base disturbance. The nurse would first note that the $\mathrm{pH}$ has returned to close to normal indicating compensation. The nurse then assess the $\mathrm{PCO}_2$ (normal: 35 to $45 \mathrm{~mm} \mathrm{Hg}$ ) and $\mathrm{HCO}_3$ (normal: 22 to $27 \mathrm{mEq} / \mathrm{L}$ ) levels. In a respiratory condition, the $\mathrm{pH}$ and the $\mathrm{PCO}_2$ move in opposite directions; thus, the $\mathrm{pH}$ rises and the $\mathrm{PCO}_2$ drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the $\mathrm{pH}$ and the bicarbonate move in the same direction; if the $\mathrm{pH}$ is low, the bicarbonate level will be low, also. In this client, the $\mathrm{pH}$ is at the high end of normal, indicating compensation and alkalosis. The $\mathrm{PCO}_2$ is low, indicating a respiratory condition (opposite direction of the $\mathrm{pH}$ ).
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.
The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?
- A. Cool and pale skin
- B. Crackles in the lung fields
- C. Distended jugular veins
- D. Dark, concentrated urine
Correct Answer: D
Rationale: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.
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 $4 \mathrm{~cm} \mathrm{H}_2 \mathrm{O}$.