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. Administering tube feedings while the client is in a supine (flat on their back) position can increase the risk of aspiration. Ideally, clients should be positioned upright or at a 30-45 degree angle during and after tube feedings to reduce the risk of reflux and aspiration.
B. Flushing the NG tube with tap water after feeding is just a standard practice to prevent clogging and maintain tube patency.

C. Administering tube feedings by gravity using a syringe barrel is an appropriate method. This allows for controlled and slow administration of the feeding solution, minimizing the risk of overfeeding or complications.
D. Aspirating gastric residual before initiating tube feedings is a standard practice to assess the amount of residual contents in the stomach. However, the amount of residual aspirate that warrants intervention can vary based on institutional policies and the client's condition.

A. Irregular B. Slow C. Not palpable D. Bounding

Correct Answer is A

Explanation

A. Atrial fibrillation is characterized by an irregularly irregular pulse. This means that the rhythm of the pulse lacks a discernible pattern; it may be irregularly fast or slow, with varying intervals between beats. Therefore, "irregular" is an appropriate term to describe the quality of the pulse in a client with atrial fibrillation.
B. While some clients with atrial fibrillation may have a slow heart rate (bradycardia), not all do. Atrial fibrillation itself typically presents with an irregular rhythm rather than a consistently slow pulse rate. Thus, "slow" may not accurately describe the quality of the pulse in atrial fibrillation.
C. "Not palpable" refers to the inability to feel or detect a pulse. In atrial fibrillation, the pulse is usually palpable but irregular. Therefore, "not palpable" would not be an accurate term to describe the pulse quality in this condition.
D. "Bounding" describes a pulse that is strong and forceful. In atrial fibrillation, the pulse may vary in strength and typically does not have a bounding quality. This term would not accurately describe the pulse quality in a client with atrial fibrillation.

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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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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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