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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 B

Explanation

Choice A rationale:

Naloxone does not have any direct effect on respiratory secretions. It works by binding to opioid receptors in the brain and reversing the effects of opioids, such as respiratory depression.

While opioids can cause a decrease in respiratory secretions, this is not the primary reason for administering naloxone.

It is important to note that naloxone can actually worsen respiratory secretions in some patients, particularly those with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.

Choice B rationale:

Naloxone is a medication that is specifically designed to block the effects of opioids on the central nervous system (CNS).

It is a competitive antagonist, which means that it binds to opioid receptors in the brain and prevents opioids from binding to those receptors.

This can reverse the effects of opioids, such as respiratory depression, sedation, and hypotension.

Naloxone is often used to treat opioid overdose, but it can also be used to prevent opioid-induced respiratory depression in patients who are receiving opioids for pain relief.

Choice C rationale:

Naloxone is not effective in treating nausea.

In fact, it can actually worsen nausea in some patients.

This is because naloxone can block the effects of opioids in the brain, and opioids can sometimes have a nausea-relieving effect.

Choice D rationale:

Naloxone is not effective in treating urinary retention.

Urinary retention is a common side effect of opioids, but it is not caused by the effects of opioids on the CNS. Urinary retention is typically caused by the effects of opioids on the bladder muscles.

A. Administer a prescribed analgesic. B. Check the patency of the tubing. C. Notify the provider. D. Offer oral fluids.

Correct Answer is B

Explanation

Choice B rationale:

Checking the patency of the tubing is the first and most crucial step in addressing the lack of urinary output in this patient. Here's a detailed explanation of why this is the priority action:

Addresses the Most Likely Cause: Obstruction of the urinary catheter tubing is the most common and easily reversible cause of sudden cessation of urinary output in a patient with a continuous bladder irrigation system.

Prevents Complications: A blocked catheter can lead to a number of serious complications, including: Bladder distention, which can cause pain, discomfort, and potential bladder damage.

Urinary retention, which can increase the risk of urinary tract infections (UTIs) and kidney damage. Hematuria, or blood in the urine, due to clot formation in the bladder or catheter.

Non-Invasive Intervention: Checking the tubing is a simple, non-invasive procedure that can quickly identify and resolve the issue without requiring further interventions or delays in care.

Prioritizes Patient Safety: It's essential to promptly address any potential urinary obstruction to prevent the aforementioned complications and ensure patient safety.

Rationale for Other Choices:

Choice A: Administering a prescribed analgesic:

While pain management is important, it does not directly address the lack of urinary output. Pain medication would be appropriate if pain were assessed to be the cause of the decreased output, but it's not the first priority in this situation.

Choice C: Notifying the provider:

Although the provider should be informed of the situation, checking the tubing for patency is a necessary first step to gather more information and potentially resolve the issue quickly without requiring further intervention.

Choice D: Offering oral fluids:

Increasing fluid intake might be helpful in some cases of decreased urinary output, but it's not the priority action in a patient with a continuous bladder irrigation system and a potential catheter obstruction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

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Correct Answer is B

Explanation

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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?