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

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

A patient who has gastroenteritis and is receiving oral fluids.

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

A patient who has NPO status since midnight for an endoscopy.

Answer and Explanation

The Correct Answer is D

Rationale for Choice A:

Diuretics promote fluid loss, increasing the risk of fluid volume deficit.

Heart failure can lead to fluid retention, but diuretic therapy is often used to manage this excess fluid.

However, in this case, the patient is receiving diuretic therapy, which suggests that their fluid status is being actively managed.

Therefore, while this patient is at risk for fluid volume deficit, they are not the most likely candidate among the options presented.

Rationale for Choice B:

Gastroenteritis can lead to fluid loss through vomiting and diarrhea.

However, this patient is receiving oral fluids, which helps to replenish lost fluids and electrolytes.

As long as the patient is able to tolerate oral fluids and is not experiencing excessive fluid losses, they are not at significant risk for fluid volume deficit.

Rationale for Choice C:

End-stage kidney disease can impair the kidneys' ability to regulate fluid balance.

However, dialysis is a treatment that helps to remove excess fluid and waste products from the body.

Therefore, while this patient is at risk for fluid volume imbalances, they are receiving treatment to manage this risk.

Rationale for Choice D:

NPO status means that the patient has been instructed to have nothing by mouth. This means that the patient has not been able to consume any fluids since midnight.

Even in the absence of excessive fluid losses, this prolonged period of fluid restriction can lead to dehydration and fluid volume deficit.

Therefore, this patient is the most likely to be experiencing fluid volume deficit among the options presented.

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Correct Answer is D

Explanation

Choice A rationale:

Notifying the facility's security department may be necessary in some cases, but it should not be the nurse's first action. This could escalate the situation and make the patient feel threatened or coerced. It's important to first attempt to de-escalate the situation and understand the patient's reasons for wanting to leave. Involving security prematurely could damage the nurse- patient relationship and make it more difficult to provide care in the future.

Security should be involved if the patient is a danger to themselves or others, or if they are attempting to leave in a way that could cause harm. However, in most cases, it is best to try to resolve the situation through communication and understanding.

Choice B rationale:

Calling the patient's family may be helpful in some cases, but it is not always necessary or appropriate. The nurse should first assess the patient's decision-making capacity and their understanding of the risks of leaving against medical advice. If the patient is capable of making their own decisions, the nurse should respect their autonomy and not involve family members without their consent.

Involving family members without the patient's consent could breach confidentiality and erode trust. It's important to balance the patient's right to privacy with the potential benefits of involving family members.

Choice C rationale:

Insisting that the patient exit the hospital via a wheelchair is not necessary in most cases. If the patient is able to walk and does not pose a safety risk, they should be allowed to leave on their own terms. Requiring a wheelchair could be seen as patronizing or controlling, and it could further upset the patient.

The use of a wheelchair should be based on the patient's individual needs and preferences, not on a blanket policy.

Choice D rationale:

Making sure the patient understands that they are leaving against medical advice is the most important action the nurse can take. This ensures that the patient is aware of the potential risks of leaving the hospital, and it protects the nurse from liability. The nurse should document the patient's decision in the medical record and have the patient sign an Against Medical Advice (AMA) form.

By ensuring informed consent, the nurse respects the patient's autonomy while also fulfilling their professional obligations.

A. Cellular hypoxia B. Fluid retention C. Prolonged bleeding D. Impaired immunity

Correct Answer is A

Explanation

Choice A rationale:

Cellular hypoxia occurs when cells do not receive enough oxygen to meet their metabolic demands. Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to the tissues. A hemoglobin level of 10.8 g/dL is below the normal range for adults (14-18 g/dL), indicating that the client has anemia. Anemia reduces the oxygen-carrying capacity of the blood, which can lead to cellular hypoxia.

Here is a detailed explanation of how anemia can lead to cellular hypoxia:

Decreased oxygen-carrying capacity: Anemia results in fewer red blood cells or reduced hemoglobin levels within those cells. As a consequence, the blood's ability to transport oxygen to the tissues is diminished.

Impaired oxygen delivery: Oxygen is transported to the tissues through the bloodstream, attached to hemoglobin within red blood cells. With fewer red blood cells or reduced hemoglobin, the delivery of oxygen to the tissues is compromised.

Decreased oxygen availability at the cellular level: As oxygen delivery is impaired, less oxygen is available to the cells for metabolic processes. This insufficient oxygen supply leads to cellular hypoxia.

Impaired cellular function: Cells require oxygen to produce energy through a process called aerobic respiration. Cellular hypoxia disrupts this process, leading to impaired cellular function.

Tissue and organ dysfunction: When a significant number of cells within a tissue or organ experience hypoxia, the function of that tissue or organ can be compromised. This can manifest in various symptoms and complications, depending on the affected organs.

Common signs and symptoms of cellular hypoxia:

Fatigue Weakness

Shortness of breath Pale skin

Dizziness Headache Chest pain

Tachycardia (rapid heart rate) Cognitive impairment

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