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 D
Explanation
Choice A rationale:
Hypokalemia is not a direct adverse effect of dextrose 10% in water infusion. This solution does not contain potassium, and unless the patient already has low potassium levels or other contributing factors, it would not cause hypokalemia.
Choice B rationale:
Hypercalcemia is unrelated to dextrose 10% in water infusion. The solution does not contain calcium, and it would not lead to an increase in serum calcium levels.
Choice C rationale:
Hypovolemia, or low blood volume, is not typically associated with dextrose 10% in water infusion. However, if administered rapidly in large amounts, it could potentially cause fluid overload leading to hypervolemia.
Choice D rationale:
Hyperglycemia is a possible adverse effect of dextrose 10% in water infusion. The solution contains a high concentration of glucose, which can raise blood sugar levels if the body cannot adequately utilize or regulate the glucose. Regular monitoring of blood glucose levels is essential during such an infusion, especially in patients with diabetes or impaired glucose tolerance.
Correct Answer is B
Explanation
Other electrolyte disturbances.
Choice A rationale:
Drug toxicity is not directly related to hypocalcemia. The main concern in hypocalcemia is the calcium imbalance itself, not drug toxicity.
Choice B rationale:
Other electrolyte disturbances should be assessed because imbalances in other electrolytes, such as potassium and magnesium, are often associated with hypocalcemia. Electrolyte imbalances can interact and exacerbate each other, potentially leading to more severe complications.
Choice C rationale:
Hypertension is not a typical assessment finding in hypocalcemia. Hypertension is not directly related to calcium levels but may have other underlying causes.
Choice D rationale:
Visual disturbances are not commonly associated with hypocalcemia. Hypocalcemia is more likely to present with neuromuscular and cardiovascular symptoms, rather than visual disturbances.
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