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.

Answer and Explanation

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.

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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.

A. Investigate the client’s emotional concerns. B. Check the client’s perianal skin integrity. C. Obtain a dietary history from the client. D. Review the client’s electrolyte values.

Correct Answer is B

Explanation

Choice A rationale
While emotional concerns are important to address in a holistic care approach, they are not the initial course of action when a client is admitted due to an acute exacerbation of ulcerative colitis. Emotional concerns are usually addressed once the client’s physical condition is stabilized.
Choice B rationale
Checking the client’s perianal skin integrity is a crucial initial step when a client is admitted due to an acute exacerbation of ulcerative colitis. Ulcerative colitis can cause rectal bleeding and diarrhea, which can lead to skin breakdown in the perianal area. Therefore, assessing for skin integrity helps in early detection and management of potential skin complications.
Choice C rationale
Obtaining a dietary history from the client is important but not the initial course of action in this scenario. Dietary history is usually obtained once the client’s condition is stabilized and when planning for discharge or dietary modifications.
Choice D rationale
Reviewing the client’s electrolyte values is important in managing ulcerative colitis, but it’s not the initial course of action. Electrolyte imbalances can occur due to diarrhea and

malabsorption, which are common in ulcerative colitis. However, this is usually done after initial physical assessments and stabilization of the client.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss. The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?

Correct Answer is A

Explanation

A nurse is attending to a client who has just been admitted due to an acute exacerbation of ulcerative colitis. What should be the nurse’s initial course of action?

Correct Answer is B

Explanation

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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?