A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

A client who has end-stage kidney disease who will undergo dialysis

A client who has gastroenteritis and is receiving oral fluids

A client who has heart failure and is receiving diuretic therapy

A client who has NPO status since midnight for an endoscopy

Answer and Explanation

The Correct Answer is B

A.   Clients with end-stage kidney disease often have impaired kidney function, leading to decreased urine output and retention of fluid and waste products. Dialysis is intended to remove excess fluid and waste from the body.
B.   Gastroenteritis involves inflammation of the gastrointestinal tract, leading to symptoms such as diarrhea and vomiting. These symptoms result in significant fluid loss.
C.   Heart failure can lead to fluid retention and edema due to the heart's inability to pump effectively. Diuretic therapy is commonly prescribed to manage fluid overload by increasing urine output. However, excessive diuresis or inadequate intake of fluids can lead to fluid volume deficit, particularly if the client does not compensate with adequate oral intake.

D.   This client has been NPO only since midnight (about 9–14 hours, depending on procedure time). While intake is restricted, this short period is not usually enough to cause a significant fluid volume deficit, unless prolonged.

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Correct Answer is B

Explanation

A. This statement is incorrect because after instilling ointment, the client should close their eye gently and avoid blinking to allow the ointment to spread over the conjunctival sac.
B. When applying ophthalmic ointment, the client should pull down the lower eyelid to create a small pocket (conjunctival sac) and then apply a thin line of ointment along this pocket. This method helps the ointment distribute evenly over the affected area.
C. While this is a correct technique for cleaning around the eye, it is not directly related to the application of ophthalmic ointment.
D. This statement is unnecessary and may confuse the client. It's typically not required to use sterile gloves for applying ophthalmic ointment, and most ointments come with a sterile applicator or can be applied using clean hands if instructed to do so by a healthcare provider.

A. Turn the client on his side before starting oral care. B. Use a stiff toothbrush to clean the client's teeth. C. Apply petroleum jelly to the client's lips after oral care. D. Use the thumb and index finger to keep the client's mouth open.

Correct Answer is A

Explanation

A. This is a crucial step to prevent aspiration (the inhalation of oral contents into the lungs). Turning the client on their side helps to facilitate drainage and prevents oral fluids and debris from entering the airway during oral care.
B. Using a stiff toothbrush can be harmful to the gums and oral tissues, especially for clients who are unresponsive and may not be able to indicate discomfort. A soft-bristled toothbrush or moistened gauze is recommended for cleaning the teeth and gums to prevent injury and maintain oral hygiene effectively.
C. Applying petroleum jelly or a similar barrier ointment helps to moisturize and protect the lips from dryness and cracking, which can be common in clients who are unresponsive and may not be able to moisten their lips independently.
D. Using the thumb and index finger to keep the client's mouth open is gentle and effective. This technique allows the nurse to visualize and clean the oral cavity adequately without causing discomfort or injury to the client.

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A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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