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
The correct answer is choice B) Administering sodium polystyrene sulfonate.
Choice A rationale:
Administering a potassium-sparing diuretic is not appropriate for a client with hyperkalemia (high potassium levels). Potassium-sparing diuretics would further increase potassium levels, worsening the condition.
Choice B rationale:
Sodium polystyrene sulfonate is used to treat hyperkalemia. It works by exchanging sodium ions for potassium ions in the intestines, which helps to lower serum potassium levels by excreting it through the stool.
Choice C rationale:
Initiating an IV potassium infusion would be contraindicated in this situation as it would increase the already elevated potassium levels, potentially leading to dangerous cardiac complications.
Choice D rationale:
Encouraging the client to eat bananas is not advisable because bananas are high in potassium, which would exacerbate hyperkalemia.
Correct Answer is ["A","D"]
Explanation
The correct answer is A. Limit intake of canned soups and D. Read labels on foods before eating.
Choice A rationale:
Canned soups often contain high levels of sodium, which can contribute to exceeding the recommended daily sodium intake. Limiting these can help manage sodium levels effectively.
Choice B rationale:
Choosing diet sodas over bottled water is not advisable. Diet sodas can still contain sodium and other additives that are not beneficial for a low-sodium diet. Bottled water is a better choice as it typically contains no sodium.
Choice C rationale:
Bottled salad dressings often contain high amounts of sodium. Opting for homemade or low-sodium versions is a better strategy for maintaining a low-sodium diet.
Choice D rationale:
Reading labels on foods before eating is crucial for identifying hidden sources of sodium and making informed dietary choices. This practice helps in adhering to a low-sodium diet by avoiding foods with high sodium content.
: 3
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