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 NPO status since midnight for an endoscopy.

A client who has heart failure and is receiving diuretic therapy.

A client who has gastroenteritis and is receiving oral fluids.

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

Answer and Explanation

The Correct Answer is B

The correct answer is choice B.

Choice A rationale:

A client who has NPO (nothing by mouth) status since midnight for an endoscopy could be at risk for fluid volume deficit. NPO status means the client has not been able to consume fluids orally, which could lead to a decrease in fluid intake. However, the risk is relatively low if the NPO status has only been in place since midnight and the client is otherwise healthy.

Choice B rationale:

A client who has heart failure and is receiving diuretic therapy is at a high risk for fluid volume deficit. Diuretics are used in heart failure to remove excess fluid from the body, but they can also lead to fluid volume deficit if not properly managed. This is because diuretics increase urine output, which can lead to a loss of fluid and electrolytes.

Choice C rationale:

A client who has gastroenteritis and is receiving oral fluids is not typically at risk for fluid volume deficit. Gastroenteritis can cause fluid loss through diarrhea and vomiting, but if the client is able to consume and retain oral fluids, they can usually maintain their fluid balance.

Choice D rationale:

A client who has end-stage kidney disease and will undergo dialysis could be at risk for fluid volume deficit, but this risk is typically well-managed during dialysis. Dialysis removes waste and excess fluid from the blood, and fluid intake is carefully monitored and adjusted based on the individual’s needs. Therefore, while there is a potential risk, it is usually well-controlled under the care of healthcare professionals.

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Correct Answer is A

Explanation

Choice A rationale:

Asking the client’s full name and date of birth is the most reliable method of identification.

Choice B rationale:

Verifying the client’s room number is not reliable because room assignments can change.

Choice C rationale:

Asking a family member to verify the client’s identity is not always possible or reliable.

Choice D rationale:

Checking the client’s name on the medication administration record (MAR) is important but should be done in conjunction with direct client identification.

A. Creating a 6 mm (1/4 in) bleb in the intradermal space of the forearm. B. Visualizing the tip of the needle under the skin. C. Stretching the skin tightly before injection. D. Withdrawing the needle and massages the site gently.

Correct Answer is D

Explanation

Choice A rationale:

Creating a 6 mm (1/4 in) bleb in the intradermal space of the forearm is the correct procedure for a Mantoux tuberculin skin test.

Choice B rationale:

Visualizing the tip of the needle under the skin is the correct procedure for a Mantoux tuberculin skin test.

Choice C rationale:

Stretching the skin tightly before injection is the correct procedure for a Mantoux tuberculin skin test.

Choice D rationale:

Withdrawing the needle and massaging the site gently is incorrect. Massaging the site can cause the test solution to disperse, which can affect the test results.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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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?