A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

The client who has end-stage renal failure and is scheduled for dialysis today.

The client who has been NPO since midnight for endoscopy.

The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL.

The client who has gastroenteritis and is febrile.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. The client who has gastroenteritis and is febrile.

Choice A rationale:

The client with end-stage renal failure scheduled for dialysis would not be at risk for fluid volume deficit because dialysis is a treatment that removes waste, salt, and extra water to prevent them from building up in the body, keeping a safe level of certain chemicals in the blood, and controlling blood pressure.

Choice B rationale:

Being NPO (nothing by mouth) since midnight for endoscopy typically involves a short period of fasting. While it could potentially contribute to a mild fluid volume deficit, it is not as significant as other causes like vomiting or diarrhea, which can lead to more substantial fluid losses.

Choice C rationale:

A client with left-sided heart failure and an elevated BNP level is more likely to experience fluid volume overload rather than a deficit. BNP is released in response to ventricular volume expansion and pressure overload, which are indicative of heart failure, not fluid volume deficit.

Choice D rationale:

The client with gastroenteritis and a fever is at risk for fluid volume deficit due to increased fluid losses from vomiting, diarrhea, and fever-induced perspiration. These symptoms align with the common risk factors for fluid volume deficit, which include vomiting, diarrhea, and sweating.

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Correct Answer is C

Explanation

Choice A rationale:

While acute renal failure can affect phosphorus levels, potassium is the electrolyte most commonly affected in this condition. Kidneys play a crucial role in regulating potassium levels in the body, and when they fail, potassium levels can become dangerously elevated.

Choice B rationale:

Acute renal failure can lead to alterations in magnesium levels, but potassium is typically more affected. Magnesium imbalances may occur but are not the primary concern in this condition.

Choice C rationale:

As mentioned earlier, potassium imbalances are common in acute renal failure. The nurse should closely monitor the patient's potassium levels and be prepared to intervene if they become too high or too low.

Choice D rationale:

Calcium levels may also be affected in acute renal failure, but potassium remains the most critical electrolyte to monitor in this condition.

A. Request a dietitian consult for selecting foods high in phosphorous. B. Provide aluminum hydroxide antacids as prescribed. C. Instruct the patient to avoid poultry, peanuts, and seeds. D. Instruct the patient to avoid the intake of sodium phosphate.

Correct Answer is A

Explanation

Choice A rationale:

Hypophosphatemia is a condition characterized by low levels of phosphate in the blood, which can be caused by various factors, including malnutrition. In this case, the patient has a history of stomach ulcers, which might have contributed to poor nutrient absorption. The nurse should request a dietitian consult to ensure the patient receives an appropriate diet rich in phosphorus, which is essential for cellular function, bone health, and energy metabolism.

Choice B rationale:

Providing aluminum hydroxide antacids as prescribed is not the appropriate intervention for hypophosphatemia. Aluminum hydroxide antacids can bind to phosphate in the gastrointestinal tract, reducing its absorption and potentially worsening the patient's already low phosphate levels.

Choice C rationale:

Instructing the patient to avoid poultry, peanuts, and seeds is not suitable for this situation. These foods are good sources of phosphorus, and avoiding them would further deplete the patient's already low phosphate levels.

Choice D rationale:

Instructing the patient to avoid the intake of sodium phosphate is not necessary for hypophosphatemia. While sodium phosphate preparations are used as laxatives, there is no indication that the patient is taking them, and they are not relevant to the management of hypophosphatemia.

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A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a patient who was diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most affected with this disorder?

Correct Answer is C

Explanation

A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. What intervention should the nurse include in this patient's plan of care?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

A patient has a serum phosphate level of 2.0 mg/dL. Which treatments should the nurse expect to be prescribed for this patient? Select all that apply.

A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

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