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 B
Explanation
Choice A rationale:
A phosphorus level of 4.5 mEq/L falls within the normal range, which is typically between 2.5 to 4.5 mEq/L. Although it's essential to monitor phosphorus levels, it is not the priority finding in this scenario.
Choice B rationale:
A potassium level of 2.9 mEq/L is the priority finding. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. A potassium level of 2.9 mEq/L indicates severe hypokalemia, which can lead to life-threatening cardiac arrhythmias and muscle weakness. Immediate intervention is necessary to address the potassium imbalance.
Choice C rationale:
A calcium level of 8.2 mg/dL falls within the normal range (typically 8.5 to 10.2 mg/dL). While calcium levels are essential to monitor, they do not take precedence over the critically low potassium level in this situation.
Choice D rationale:
A sodium level of 145 mEq/L falls within the normal range, which is usually around 135 to 145 mEq/L. Although monitoring sodium levels is important, it is not the priority finding when compared to the critically low potassium level.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
The nurse considered contraction of facial muscles as a finding of hypocalcemia because it is associated with Chvostek's sign, which indicates neuromuscular irritability due to low calcium levels.
Choice B rationale:
Complaints of fingers tingling are indicative of hypocalcemia since tingling sensations (paresthesias) in the extremities can result from decreased calcium levels affecting nerve function.
Choice C rationale:
Carpal spasm with blood pressure measurement is known as Trousseau's sign and is associated with hypocalcemia. When the blood pressure cuff is inflated above systolic pressure, it can cause tetany in the hand if the calcium levels are low.
Choice D rationale:
Asking when foot numbness would go away does not directly relate to hypocalcemia or its symptoms. It is not a finding used to come to the conclusion of hypocalcemia in this scenario.
Choice E rationale:
The heart rate being 88 and regular does not directly indicate hypocalcemia. While hypocalcemia can lead to cardiac arrhythmias, a heart rate of 88 and regular is within the normal range and not a specific finding for hypocalcemia.
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