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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A, D, and E.
Choice A rationale:
Furosemide is a loop diuretic that promotes diuresis, causing an increase in urine output. It is essential for the patient to expect this effect and understand that it helps in reducing fluid overload.
Choice B rationale:
Feeling weak and dizzy is not an expected effect of furosemide. It is more commonly associated with dehydration or excessive fluid loss, which can occur if the medication causes too much diuresis.
Choice C rationale:
Taking furosemide before going to sleep is not recommended because it can lead to nighttime diuresis, disrupting sleep and potentially causing electrolyte imbalances.
Choice D rationale:
Swelling of the face or hands may indicate an adverse reaction to furosemide or an underlying medical issue. The nurse should instruct the patient to report any such symptoms promptly.
Choice E rationale:
Monitoring body weight daily is crucial for patients on diuretic therapy to assess fluid status and response to treatment. Rapid weight gain may indicate worsening fluid overload, while significant weight loss may indicate excessive diuresis.
Correct Answer is ["B","C","D"]
Explanation
The correct answers are Choices B, C, and D.
Choice A rationale: Normal saline is not typically used to treat low phosphate levels. It is often used to treat dehydration and electrolyte imbalances that do not include hypophosphatemia.
Choice B rationale: Potassium phosphate is used to treat low phosphate levels. It directly supplements phosphate levels in the body, making it an appropriate treatment for hypophosphatemia.
Choice C rationale: Additional milk intake can help increase phosphate levels, as milk is a good source of phosphate. This is a suitable recommendation for a patient with low phosphate levels.
Choice D rationale: Increased Vitamin D intake can enhance phosphate absorption from the gastrointestinal tract, making it a beneficial treatment for a patient with low phosphate levels.
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