Nokea
The nursing instructor is talking with the nursing class about fluid and electrolyte balance. What would the instructor tell the students that the average daily fluid intake for an adult is?
- A. 2000 mL
- B. 2500 mL
- C. 3000 mL
- D. 3500 mL
Correct Answer: B
Rationale: In healthy adults, oral fluid intake averages about $2500 \mathrm{~mL} /$ day; however, it can range between 1800 and $3000 \mathrm{~mL} /$ day, with a similar volume of fluid loss. $2000 \mathrm{~mL}, 3000 \mathrm{~mL}$, and $3500 \mathrm{~mL}$ are not the average amounts of fluid a healthy adult takes in daily.
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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.
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 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.
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.
The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?
- A. A blood pressure elevation upon activity
- B. A drop in systolic blood pressure $(15 \mathrm{~mm} \mathrm{Hg}$ ) upon rising
- C. A pulsating headache
- D. A drop in diastolic blood pressure $(25 \mathrm{mmHg}$ ) upon rising
Correct Answer: B
Rationale: Postural hypotension occurs when the client rises from a supine or semi- Fowler's position to a standing position and the systolic blood pressure drops by $15 \mathrm{~mm} \mathrm{Hg}$. The client has symptoms of dizziness or a near syncopal episode.