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 D
Explanation
Choice A reason: Respiratory alkalosis is caused by hyperventilation, which lowers the carbon dioxide levels in the blood and raises the pH. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice B reason: Metabolic acidosis is caused by an excess of acids or a loss of bases in the body, which lowers the pH. This can occur in conditions such as diabetic ketoacidosis, renal failure, or diarrhea. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice C reason: Respiratory acidosis is caused by hypoventilation, which raises the carbon dioxide levels in the blood and lowers the pH. This can occur in conditions such as chronic obstructive pulmonary disease, asthma, or sedative overdose. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice D reason: Metabolic alkalosis is caused by a loss of acids or an excess of bases in the body, which raises the pH. This can occur in conditions such as vomiting, gastric suction, or diuretic use. This is the most likely acid-base disorder to occur in a client with a nasogastric tube on low suction, as the tube removes gastric acid from the stomach.
Correct Answer is A
Explanation
Choice A reason: This is correct because acidosis is a condition where the serum pH is lower than the normal range of 7.35 to 7.45. Acidosis can be caused by an excess of acids or a loss of bases in the body, which can affect the function of various organs and systems.
Choice B reason: This is incorrect because equal bicarbonate is not a condition, but a term that describes the balance between bicarbonate (HCO3-) and carbonic acid (H2CO3) in the blood. Bicarbonate is a base that buffers the acids in the blood and maintains the pH. Equal bicarbonate means that the ratio of bicarbonate to carbonic acid is 20:1, which is the normal value.
Choice C reason: This is incorrect because neutral carbonic acid is not a condition, but a term that describes the pH of carbonic acid (H2CO3) in the blood. Carbonic acid is an acid that forms when carbon dioxide (CO2) dissolves in water. Neutral carbonic acid means that the pH of carbonic acid is 7.0, which is neither acidic nor basic.
Choice D reason: This is incorrect because alkalosis is a condition where the serum pH is higher than the normal range of 7.35 to 7.45. Alkalosis can be caused by a loss of acids or an excess of bases in the body, which can affect the function of various organs and systems.
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