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
Cerebral bleeding. Choice A rationale:
Stress fractures are not directly related to hypernatremia. Hypernatremia is an electrolyte imbalance, and its main effects are related to cellular dehydration and neurological symptoms rather than bone fractures.
Choice B rationale:
This is the correct answer because hypernatremia can lead to severe dehydration and cause neurological complications, including cerebral bleeding. The brain cells can shrink due to water loss, causing blood vessels to rupture, leading to bleeding in the brain.
Choice C rationale:
Atrial dysrhythmias are not directly associated with hypernatremia. Hypernatremia primarily affects the central nervous system and can lead to neurological symptoms rather than cardiac dysrhythmias.
Choice D rationale:
Pulmonary edema is not a likely consequence of hypernatremia. Pulmonary edema is associated with fluid volume excess, not fluid volume deficit, which is characteristic of hypernatremia.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
Dysrhythmias are not a direct consequence of diabetic ketoacidosis (DKA) or the acid-base imbalance indicated by the patient's pH of 7.2 and bicarbonate level of 20 mEq/L. DKA primarily affects the respiratory system, leading to Kussmaul respirations, not dysrhythmias.
Choice B rationale:
Kussmaul respirations are an expected finding in a patient with diabetic ketoacidosis (DKA) and metabolic acidosis. These deep, rapid breaths are the body's attempt to compensate for the acidosis by eliminating excess CO2.
Choice C rationale:
Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.
Choice D rationale:
Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.
Choice E rationale:
Tachycardia is an expected finding in a patient with DKA. The metabolic acidosis and dehydration lead to an increase in heart rate as the body attempts to maintain perfusion.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today