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 D

Explanation

Choice A rationale:

Increased urine ketones are not indicative of fluid volume deficit. Instead, they may suggest diabetic ketoacidosis or starvation ketosis.

Choice B rationale:

Decreased Hgb (hemoglobin) is not specific to fluid volume deficit and can be seen in various conditions such as anemia or bleeding.

Choice C rationale:

Decreased urine specific gravity is not consistent with fluid volume deficit, as it usually results in concentrated urine with increased specific gravity.

Choice D rationale:

An increased blood urea nitrogen (BUN) level is expected in fluid volume deficit due to reduced kidney perfusion and function. BUN is a marker of kidney function and is elevated when fluid volume is low.

A. Hypocalcemia B. Hypernatremia. C. Hyperkalemia. D. D. Potential Condition. Action to Take 1: Prepare to check a serum albumin level. Action to Take 2: Request a STAT ECG. Parameters to Monitor 1: Serum bicarbonate level. Parameters to Monitor 2: Intake and Output.

Correct Answer is D

Explanation

Potential Condition.

Based on the provided information, it's challenging to make a definitive diagnosis with the given laboratory results and clinical presentation. The client's symptoms, such as severe abdominal pain, vomiting, dyspnea, yellow sclera, dry mucous membranes, tachycardia, and positive Chvostek and Trousseau signs, suggest a complex clinical picture that requires further investigation and assessment. Action to Take 1: Notify the provider. Rationale: The client's condition appears to be critical and requires immediate medical attention. Notifying the provider will initiate a comprehensive evaluation and potential interventions. Action to Take 2: Withhold medication for diarrhea until the underlying cause is determined. Rationale: Diarrhea can be a symptom of various conditions, and administering medication without a clear diagnosis may mask important clinical information. Parameters to Monitor 1: Serum bicarbonate level.

Rationale:

Monitoring serum bicarbonate levels can help identify potential acid-base imbalances and assess the client's metabolic status, especially given the history of end-stage renal disease. Parameters to Monitor 2: Intake and Output. Rationale: Monitoring intake and output is essential to assess fluid balance and kidney function, especially in a client with end- stage renal disease and potential electrolyte imbalances.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

A patient's blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. The nurse realizes that the patient is demonstrating which acid-base disorder?

The nurse is caring for a patient diagnosed with hypocalcemia. What additional assessments should the nurse include when caring for this patient?

A nurse is planning to teach a client about a high-potassium diet. Which of the following foods should the nurse instruct the client to eat? (Select all that apply.).

A patient with fluid overload is prescribed furosemide (Lasix) 20 mg by mouth each day. What should the nurse include when teaching the patient about this medication? Select all that apply.

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?

A nurse is teaching a client who is on a low-sodium diet. Which of the following instructions should the nurse include? (Select All that Apply.).

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?