Nokea
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?
- A. Abnormal potassium level
- B. Elevated hematocrit level
- C. Low white blood count
- D. Low urine specific gravity
Correct Answer: B
Rationale: When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.
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The nurse is assigned a client with calcium level of $4.0 \mathrm{mg} / \mathrm{dL}$. Which system assessment would the nurse ask detailed questions?
- A. Endocrine system
- B. Gastrointestinal system
- C. Neurological system
- D. Musculoskeletal system
Correct Answer: C
Rationale: A client with a calcium level of $4.0 \mathrm{mg} / \mathrm{dL}$ has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.
The nurse is instructing on the body's negative feedback loop to ensure homeostasis to a group of students. Which action by bases keeps the blood $\mathrm{pH}$ nearly neutral?
- A. Bases cast off acids.
- B. Bases bind with hydrogen.
- C. Bases hold acidic properties.
- D. Bases have no contact with acids.
Correct Answer: B
Rationale: Acids are substances that release hydrogen into fluid, bases are substances that bind with hydrogen. The delicate balance between acids and bases, as well as fluids and electrolytes, maintains the nearly neutral blood $\mathrm{pH}$.
The nurse is reviewing client lab work for a critical lab value. Which value is called to the health care provider for additional prescriptions?
- A. Potassium: $5.8 \mathrm{mEq} / \mathrm{L}$
- B. Sodium: $138 \mathrm{mEq} / \mathrm{L}$
- C. Magnesium: $2 \mathrm{mEq} / \mathrm{L}$
- D. Calcium: $10 \mathrm{mg} / \mathrm{dL}$
Correct Answer: A
Rationale: Normal potassium level is 3.5 to $5.5 \mathrm{mEq} / \mathrm{L}$. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.
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.
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.