The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit?
The client with an ileostomy
The client with cirrhosis
The client with heart failure
The client with decreased renal function
The Correct Answer is A
Choice A reason: The client with an ileostomy is at risk for fluid volume deficit because an ileostomy is a surgical opening in the ileum, the last part of the small intestine, that allows the drainage of intestinal contents. This can result in a loss of fluids and electrolytes, especially sodium and potassium, which can lead to dehydration and hypovolemia.
Choice B reason: The client with cirrhosis is not at risk for fluid volume deficit, but rather fluid volume excess. Cirrhosis is a chronic liver disease that causes scarring and impaired liver function. This can lead to portal hypertension, which is an increase in the pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can cause ascites, which is the accumulation of fluid in the abdominal cavity, and edema, which is the swelling of the tissues due to fluid retention.
Choice C reason: The client with heart failure is not at risk for fluid volume deficit, but rather fluid volume excess. Heart failure is a condition where the heart is unable to pump enough blood to meet the body's needs. This can lead to congestion of the blood vessels, which can cause pulmonary edema, which is the accumulation of fluid in the lungs, and peripheral edema, which is the swelling of the extremities due to fluid retention.
Choice D reason: The client with decreased renal function is not at risk for fluid volume deficit, but rather fluid volume excess. Decreased renal function is a condition where the kidneys are unable to filter the blood and remove excess fluids and wastes. This can lead to oliguria, which is a decrease in urine output, and anuria, which is the absence of urine output. This can cause fluid overload, which can affect the heart and the lungs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Renal failure can cause hyperkalemia because the kidneys are unable to excrete excess potassium from the body. This can lead to high levels of potassium in the blood, which can affect the heart and muscles.
Choice B reason: Diarrhea can cause hypokalemia, not hyperkalemia, because it can lead to loss of potassium from the gastrointestinal tract. This can result in low levels of potassium in the blood, which can also affect the heart and muscles.
Choice C reason: Blood transfusion can cause hyperkalemia if the blood is old or hemolyzed, meaning that the red blood cells have broken down and released potassium into the plasma. This can increase the potassium levels in the recipient's blood.
Choice D reason: Diaphoresis, or sweating, can cause hypokalemia, not hyperkalemia, because it can lead to loss of potassium from the skin. This can also lower the potassium levels in the blood.
Correct Answer is A
Explanation
Choice A reason: This is correct because 3.5 to 5.0 mEq/L is the normal range of serum potassium level in adults. Potassium is an electrolyte that is important for nerve and muscle function, as well as acid-base balance.
Choice B reason: This is incorrect because 8.5 to 10.5 mg/dL is the normal range of serum calcium level in adults, not potassium. Calcium is an electrolyte that is involved in bone health, muscle contraction, and blood clotting.
Choice C reason: This is incorrect because 135 to 145 mEq/L is the normal range of serum sodium level in adults, not potassium. Sodium is an electrolyte that is essential for fluid balance, nerve transmission, and muscle contraction.
Choice D reason: This is incorrect because 1.8 to 2.6 mEq/L is the normal range of serum magnesium level in adults, not potassium. Magnesium is an electrolyte that is important for muscle and nerve function, as well as enzyme activity.
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