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NurseDive Free Nursing Practice Question
A nurse is caring for a client who has hypernatremia and is receiving intravenous (IV) hypotonic fluid replacement. Which of the following manifestations should the nurse understand is an indication of an adverse effect from the administration of hypotonic fluids?
A. The client has developed confusion.
The client has developed confusion: Hypotonic fluids can cause a rapid shift of water into cells, potentially leading to cerebral edema. This can manifest as confusion or altered mental status, which is a serious adverse effect requiring immediate attention.
B. The client's serum sodium is 140 mEq/L (135 to 145 mEq/L).
The client's serum sodium is 140 mEq/L (135 to 145 mEq/L): A serum sodium level within the normal range indicates that the hypotonic fluid therapy is likely effective in correcting hypernatremia, and does not suggest an adverse effect.
C. The client has a positive Chvostek's sign.
The client has a positive Chvostek's sign: A positive Chvostek's sign is indicative of hypocalcemia rather than an adverse effect of hypotonic fluid administration. This sign is related to low calcium levels and is not a direct result of hypotonic fluid therapy.
D. The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL).
The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL): This BUN level is within normal limits and does not suggest an adverse effect of hypotonic fluid therapy. BUN levels can be affected by various factors, but this value alone is not indicative of an adverse reaction.
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Full Explanation
A. The client has developed confusion: Hypotonic fluids can cause a rapid shift of water into cells, potentially leading to cerebral edema. This can manifest as confusion or altered mental status, which is a serious adverse effect requiring immediate attention.
B. The client's serum sodium is 140 mEq/L (135 to 145 mEq/L): A serum sodium level within the normal range indicates that the hypotonic fluid therapy is likely effective in correcting hypernatremia, and does not suggest an adverse effect.
C. The client has a positive Chvostek's sign: A positive Chvostek's sign is indicative of hypocalcemia rather than an adverse effect of hypotonic fluid administration. This sign is related to low calcium levels and is not a direct result of hypotonic fluid therapy.
D. The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL): This BUN level is within normal limits and does not suggest an adverse effect of hypotonic fluid therapy. BUN levels can be affected by various factors, but this value alone is not indicative of an adverse reaction.
Similar Questions
Which of the following are the most common manifestations of COPD? (Select all that apply.)
A. Dyspnea
Dyspnea: Shortness of breath or difficulty breathing is a hallmark symptom of COPD, commonly reported by patients.
B. Chronic cough
Chronic cough: A persistent cough, often productive, is a common manifestation of COPD, reflecting the chronic inflammation and irritation of the airways.
C. Wheezing
Wheezing: Wheezing, a high-pitched whistling sound during breathing, is often present in COPD due to airway narrowing and obstruction.
D. Sputum production
Sputum production: Increased production of sputum (mucus) is typical in COPD, as the chronic inflammation leads to mucus hypersecretion.
E. Chest tightness
Chest tightness: While chest tightness can occur in COPD, it is less common compared to the more prominent symptoms of dyspnea, chronic cough, wheezing, and sputum production.
Full Explanation
A. Dyspnea: Shortness of breath or difficulty breathing is a hallmark symptom of COPD, commonly reported by patients.
B. Chronic cough: A persistent cough, often productive, is a common manifestation of COPD, reflecting the chronic inflammation and irritation of the airways.
C. Wheezing: Wheezing, a high-pitched whistling sound during breathing, is often present in COPD due to airway narrowing and obstruction.
D. Sputum production: Increased production of sputum (mucus) is typical in COPD, as the chronic inflammation leads to mucus hypersecretion.
E. Chest tightness: While chest tightness can occur in COPD, it is less common compared to the more prominent symptoms of dyspnea, chronic cough, wheezing, and sputum production.
A nurse is assisting with the care of a client who has chronic obstructive pulmonary disease (COPD) and is short of breath. When reviewing the client's arterial blood gases (ABGs), which of the following conditions should the nurse anticipate the client to be experiencing?
A. Respiratory acidosis
Respiratory acidosis: COPD often results in impaired gas exchange and decreased removal of carbon dioxide, leading to its accumulation in the blood. This results in respiratory acidosis, characterized by elevated PaCO2 and a decreased pH.
B. Respiratory alkalosis
Respiratory alkalosis: This condition is generally associated with hyperventilation, where excessive loss of carbon dioxide leads to a higher blood pH. It is less common in COPD, where hypoventilation is more typical.
C. Metabolic acidosis
Metabolic acidosis: While COPD can sometimes lead to metabolic acidosis, it is not the primary condition associated with the disease. Metabolic acidosis usually results from conditions affecting the kidneys or metabolic processes.
D. Metabolic alkalosis
Metabolic alkalosis: This is characterized by an increased blood pH due to a loss of acid or an excess of bicarbonate. It is not typically associated with COPD.
Full Explanation
A. Respiratory acidosis: COPD often results in impaired gas exchange and decreased removal of carbon dioxide, leading to its accumulation in the blood. This results in respiratory acidosis, characterized by elevated PaCO2 and a decreased pH.
B. Respiratory alkalosis: This condition is generally associated with hyperventilation, where excessive loss of carbon dioxide leads to a higher blood pH. It is less common in COPD, where hypoventilation is more typical.
C. Metabolic acidosis: While COPD can sometimes lead to metabolic acidosis, it is not the primary condition associated with the disease. Metabolic acidosis usually results from conditions affecting the kidneys or metabolic processes.
D. Metabolic alkalosis: This is characterized by an increased blood pH due to a loss of acid or an excess of bicarbonate. It is not typically associated with COPD.
A nurse is reviewing the medical record of a client who has metabolic acidosis. The nurse should realize that which of the following findings contributes to the development of metabolic acidosis?
A. Diarrhea
Diarrhea: Diarrhea leads to the loss of bicarbonate, an important buffer in the blood, which can contribute to the development of metabolic acidosis as the body loses bicarbonate faster than it can replace it.
B. Vomiting
Vomiting: Vomiting typically leads to metabolic alkalosis due to the loss of stomach acid, which reduces the amount of hydrogen ions in the body.
C. Salicylate intoxication
Salicylate intoxication: This condition primarily causes a mixed acid-base disturbance, including metabolic acidosis and respiratory alkalosis, due to its effects on both the metabolic and respiratory systems.
D. Hyperventilation
Hyperventilation: This condition causes respiratory alkalosis due to excessive loss of carbon dioxide, not metabolic acidosis.
Full Explanation
A. Diarrhea: Diarrhea leads to the loss of bicarbonate, an important buffer in the blood, which can contribute to the development of metabolic acidosis as the body loses bicarbonate faster than it can replace it.
B. Vomiting: Vomiting typically leads to metabolic alkalosis due to the loss of stomach acid, which reduces the amount of hydrogen ions in the body.
C. Salicylate intoxication: This condition primarily causes a mixed acid-base disturbance, including metabolic acidosis and respiratory alkalosis, due to its effects on both the metabolic and respiratory systems.
D. Hyperventilation: This condition causes respiratory alkalosis due to excessive loss of carbon dioxide, not metabolic acidosis.