A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?
Client taking furosemide (Lasix)
Anxious client who has tachypnea
Client who is on fluid restrictions
Client who is constipated with abdominal pain
The Correct Answer is B
A. Client taking furosemide (Lasix): Furosemide is a diuretic that primarily affects urine volume and does not directly increase insensible water loss. Insensible water loss refers to water lost through skin and respiratory routes, not through urination.
B. Anxious client who has tachypnea: Tachypnea, or rapid breathing, increases the rate of water loss through the respiratory system (insensible water loss). When breathing rapidly, the body loses more moisture in the form of vapor, making this client at greatest risk.
C. Client who is on fluid restrictions: Although fluid restrictions limit overall intake, this does not increase the risk for insensible water loss, which occurs primarily through skin and respiratory loss. Fluid restriction impacts overall fluid balance rather than insensible losses.
D. Client who is constipated with abdominal pain: Constipation and abdominal pain may contribute to some discomfort or difficulty with fluid intake, but they are not related to increased insensible water loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Chronic alcoholism: Chronic alcoholism is strongly associated with decreased magnesium levels. Alcohol can lead to magnesium depletion due to poor dietary intake, increased renal excretion, and impaired magnesium absorption.
B. Renal failure: Renal failure typically leads to an increase in magnesium levels because the kidneys are unable to excrete it effectively. Therefore, renal failure is more commonly associated with hypermagnesemia, not hypomagnesemia.
C. Addison's disease: Addison's disease is primarily related to adrenal insufficiency, affecting sodium, potassium, and cortisol levels, but it does not typically result in decreased magnesium levels. Hypomagnesemia is not a hallmark of Addison's disease.
D. Uncontrolled diabetes mellitus: Uncontrolled diabetes can lead to electrolyte imbalances, including potassium and sodium, but it is not directly linked to magnesium deficiency. Although magnesium loss can occur in DKA, it is not as strongly associated with diabetes as it is with chronic alcoholism.
Correct Answer is ["A","B","D"]
Explanation
A. Dyspnea: Dyspnea, or difficulty breathing, can be a sign of fluid volume excess. Fluid overload can cause pulmonary congestion and lead to respiratory distress. This is a critical manifestation that should be reported.
B. Edema: Edema is a common sign of fluid retention, especially in the lower extremities, and is indicative of fluid volume excess. This should be monitored and reported if observed during the transfusion.
C. Bradycardia: Bradycardia is typically not a sign of fluid volume excess. In fluid volume excess, the heart often tries to compensate for the increased fluid by increasing its rate (tachycardia) to maintain cardiac output, or the rate might remain relatively normal.
D. Hypertension: Hypertension, or high blood pressure, can occur with fluid volume excess as the extra fluid in the circulatory system increases the workload on the heart and raises blood pressure. This is a critical sign of fluid overload that requires reporting.
E. Weakness: Weakness can occur in a variety of conditions, including fluid volume excess, but it is a nonspecific symptom. It is less directly associated with fluid overload compared to the other findings like dyspnea, edema, and hypertension.
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