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 C
Explanation
Choice A reason: This is incorrect because respiratory alkalosis is a condition where the blood pH is higher than the normal range of 7.35 to 7.45, due to hyperventilation, which lowers the carbon dioxide in the blood. Severe diarrhea does not cause hyperventilation, but rather dehydration and electrolyte imbalance.
Choice B reason: This is incorrect because metabolic alkalosis is a condition where the blood pH is higher than the normal range of 7.35 to 7.45, due to a loss of acids or an excess of bases in the body. Severe diarrhea does not cause a loss of acids or an excess of bases, but rather a loss of fluids and bicarbonate, which is a base that buffers the acids in the blood.
Choice C reason: This is correct because metabolic acidosis is a condition where the blood pH is lower than the normal range of 7.35 to 7.45, due to an excess of acids or a loss of bases in the body. Severe diarrhea causes a loss of fluids and bicarbonate, which is a base that buffers the acids in the blood. This leads to an accumulation of acids and a decrease in pH.
Choice D reason: This is incorrect because respiratory acidosis is a condition where the blood pH is lower than the normal range of 7.35 to 7.45, due to impaired gas exchange or hypoventilation, which causes carbon dioxide to accumulate in the blood. Severe diarrhea does not affect the respiratory system directly, but rather the metabolic system.
Correct Answer is A
Explanation
Choice A reason: Narrow, peaked T waves are a sign of hyperkalemia, which is a high level of potassium in the blood. Potassium is an electrolyte that affects the electrical activity of the heart. Hyperkalemia can cause the T waves, which represent the repolarization of the ventricles, to become narrow and peaked, indicating a rapid and excessive repolarization.
Choice B reason: ST elevation is a sign of myocardial infarction, which is a heart attack. It indicates that the myocardium, or the heart muscle, is damaged and deprived of oxygen. ST elevation is not related to the potassium level, but rather to the coronary artery blood flow.
Choice C reason: Peaked P waves are a sign of atrial hypertrophy, which is an enlargement of the atria, the upper chambers of the heart. It indicates that the atria are under increased pressure or workload. Peaked P waves are not related to the potassium level, but rather to the atrial function.
Choice D reason: Prominent U waves are a sign of hypokalemia, which is a low level of potassium in the blood. Potassium is an electrolyte that affects the electrical activity of the heart. Hypokalemia can cause the U waves, which represent the repolarization of the Purkinje fibers, to become prominent and visible, indicating a delayed and prolonged repolarization.
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