A client with heart failure is receiving intravenous fluids at 125 ml/hour. The nurse observes an increase in jugular vein distention and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider?

Correct Answer: C

Rationale: Before reporting worsening heart failure signs like jugular vein distention and pedal edema, the nurse should assess for a change in breathing pattern. These symptoms suggest fluid overload, which can lead to pulmonary edema, a life-threatening complication. Altered breathing (e.g., dyspnea, crackles) indicates the heart's inability to handle the IV fluid load, necessitating urgent intervention like diuretics or rate adjustment. Calf inflammation, vein distention, and pulse volume are less immediate than respiratory status in this context.

Correct Answer: B

Rationale: To determine glucose in the urine, first calculate the glucose filtration rate: Blood glucose (900 mg/dl) × GFR (assume normal 125 ml/min) = 900 mg/dl × 1.25 dl/min = 1125 mg/min. The tubular maximum (Tmax) for glucose reabsorption is 380 mg/min. Any glucose filtered beyond Tmax is excreted: 1125 - 380 = 745 mg/min. This reflects glucosuria due to exceeding reabsorption capacity, common in hyperglycemia, making B correct.

Correct Answer: C

Rationale: Urine excretion refers to the final elimination of substances from the body via urine, encompassing filtration, reabsorption, and secretion processes. Tubular secretion (A) adds substances to the filtrate, reabsorption (B) retrieves them, and filtration (D) initiates the process, but ‘excretion' specifically denotes the output, making C correct.

Correct Answer: B

Rationale: Intracellular potassium (K⁺) concentration is approximately 150 mM, maintained by the Na⁺/K⁺-ATPase pump, which exchanges Na⁺ out for K⁺ in, creating a high K⁺ gradient inside cells (e.g., tubular cells). Extracellular K⁺ is 3.5-5 mM (C), 125 mM is close but typical for some texts (A), and 100 mM is too low, making B the standard value.

Correct Answer: A

Rationale: As hydrogen ion concentration ([H⁺]) increases, pH decreases per pH = -log[H⁺], indicating acidosis (pH < 7.35). Conversely, decreased [H⁺] raises pH, causing alkalosis. Option A correctly pairs rising [H⁺] with falling pH and acidosis, while B, C, and D misalign definitions, making A correct.