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
Digoxin. Choice A rationale:
Potassium chloride (KCL) is a supplement used to treat or prevent low potassium levels. While it can have side effects, visual disturbances are not typically associated with KCL. Therefore, it is not the medication the nurse suspects to be causing the problem.
Choice B rationale:
Warfarin (Coumadin) is an anticoagulant used to prevent blood clot formation. Visual disturbances are not a known side effect of warfarin. Therefore, it is unlikely to be the cause of the patient's symptoms.
Choice C rationale:
Aspirin (ASA) is a pain reliever and antiplatelet medication, and while it can cause visual disturbances in some cases, it is not a common or significant side effect. Aspirin is also not specifically linked to atrial fibrillation.
Choice D rationale:
Digoxin (Lanoxin) is used to treat atrial fibrillation and heart failure. Visual disturbances are a known side effect of digoxin toxicity. Given the patient's diagnosis of atrial fibrillation and the reported symptoms, the nurse suspects the problem lies with digoxin and should further investigate and report to the provider.
Correct Answer is D
Explanation
Extracellular fluid deficit.
Choice A rationale:
Intracellular fluid deficit is a decrease in the fluid inside the cells, which may occur in conditions such as diabetic ketoacidosis. Severe burns are more likely to cause extracellular fluid shifts rather than intracellular fluid deficits.
Choice B rationale:
Interstitial fluid deficit involves a decrease in fluid in the interstitial spaces between cells. While burns can lead to fluid shifts, the primary concern is fluid loss from the vascular space (extracellular fluid).
Choice C rationale:
Intracellular fluid overload is not a typical health problem associated with severe burns. Burn injuries are more likely to cause fluid loss and shifts out of the intracellular space.
Choice D rationale:
Severe burns can result in significant loss of plasma and extracellular fluid, leading to hypovolemia and extracellular fluid deficit. This fluid loss can lead to hypovolemic shock and other complications if not adequately managed.
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