A nurse is caring for four hospitalized patients.
Which of the following patients should the nurse identify as being at risk for fluid volume deficit?
The patient who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL.
The patient who has been NPO since midnight for endoscopy.
The patient who has gastroenteritis and is febrile.
The patient who has end-stage renal failure and is scheduled for dialysis today.
The Correct Answer is C
Choice A rationale
While heart failure can lead to fluid volume imbalances, a BNP level of 600 pg/mL alone does not indicate a risk for fluid volume deficit.
Choice B rationale
Being NPO since midnight for an endoscopy could potentially lead to fluid volume deficit, but it’s not the most likely choice. Typically, patients are adequately hydrated before and after the procedure.
Choice C rationale
A patient with gastroenteritis and a fever is at high risk for fluid volume deficit. Gastroenteritis can cause significant fluid loss through vomiting and diarrhea, and fever increases insensible water loss.
Choice D rationale
While patients with end-stage renal failure can have fluid volume imbalances, they are more likely to experience fluid volume excess, especially if they are due for dialysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Auscultation of a bruit over the pedal pulse is not a typical symptom of DVT. A bruit is a sound heard over an artery due to turbulent blood flow. While it may indicate vascular disease, it is not a symptom of DVT121314.
Choice B rationale
Groin tenderness can be a symptom of DVT. DVT often causes pain or tenderness in the affected area, which can include the groin.
Choice C rationale
Pallor in the affected extremity is not a typical symptom of DVT. DVT can cause swelling and warmth in the affected area, but it does not typically cause pallor.
Choice D rationale
Cramping pain in one foot is not a typical symptom of DVT. DVT often causes pain or swelling in the affected leg, but the pain is not typically limited to the foot.
Correct Answer is A
Explanation
Choice A rationale
If a client reports chills and back pain during a blood transfusion, and their blood pressure is 80/64 mm Hg, the nurse’s first action should be to stop the infusion of blood. These symptoms could indicate an acute intravascular hemolytic transfusion reaction, and the greatest risk to the client is injury from receiving additional blood.
Choice B rationale
Notifying the laboratory is an important step in managing a transfusion reaction, but it is not the first action that should be taken.
Choice C rationale
Obtaining a urine specimen could be part of the overall assessment of the client’s condition, but it is not the first action that should be taken when a client is experiencing a potential transfusion reaction.
Choice D rationale
Informing the provider is an important step when a client is experiencing a reaction to a blood transfusion, but it is not the first action that should be taken.
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