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 A

Explanation

A. After administering the injection, activating the passive needle-safety device involves a mechanism where the safety feature automatically engages. This can include a shield that covers the needle or a mechanism that retracts the needle into the syringe or device. It's crucial to activate this immediately after injection to prevent accidental needlestick injuries.
B. The safety device, once activated, should remain in place and intact on the needle until it is safely disposed of in an appropriate sharps container. Removing the safety device before disposal would expose healthcare workers to potential needlestick injuries.
C. There is no need to make sure the needle retracts into the barrel of the syringe, as the safety device is designed to cover the needle after use.
D. While some devices have a plastic sheath or shield that covers the needle before and after use, the primary action for a passive device is to activate the safety feature that automatically covers or retracts the needle post-injection. Pulling a sheath over the needle manually is more typical for active safety devices or conventional needles with manual sheath covers.

A. Urinary frequency B. Urinary tract Infection C. Urinary incontinence D. Urinary retention

Correct Answer is B

Explanation

A. Urinary frequency refers to the need to urinate more often than usual. It does not typically cause changes in the color, clarity, or odor of urine. It may be associated with conditions like urinary tract infections (UTIs) or other urinary issues but does not directly cause dark amber, cloudy, or foul-smelling urine.
B. A UTI is a common cause of changes in urine characteristics. Dark amber color can indicate concentrated urine due to dehydration or the presence of blood. Cloudiness suggests the presence of pus or bacteria, while an unpleasant odor can be due to bacterial growth. UTIs often cause these symptoms due to inflammation and infection of the urinary tract.
C. Urinary incontinence refers to involuntary loss of urine. It does not typically cause changes in the appearance or odor of urine unless it leads to urine pooling and subsequent bacterial growth, which could potentially cause odor. However, incontinence itself is not a direct cause of dark amber, cloudy urine with an unpleasant odor.
D. Urinary retention occurs when the bladder does not empty completely or at all. It can lead to concentrated urine (dark amber color) due to prolonged storage in the bladder. Cloudiness and an unpleasant odor can occur if there is bacterial growth in stagnant urine. Therefore, urinary retention can contribute to the observed urine characteristics.

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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

A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

Correct Answer is B

Explanation

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