A nurse is caring for several clients on a medical-surgical unit.
Which of the following clients have an elevated risk for fluid volume excess (FVE)? (Select all that apply.)
A 20-year-old client who is taking spironolactone.
A client who is 80 years old with nasogastric suctioning.
A 40-year-old client who has syndrome of inappropriate antidiuretic hormone (SIADH).
A client who is 65 years old and has renal impairment.
A 70-year-old client who has heart failure.
Correct Answer : C,D,E
Choice A rationale
Spironolactone is a potassium-sparing diuretic that functions by antagonizing aldosterone receptors in the distal renal tubules. This action promotes the excretion of sodium and water while retaining potassium, which effectively reduces total body fluid volume. Therefore, a client taking this medication is at a significantly lower risk for fluid volume excess. In fact, they are more likely to experience fluid volume deficit or hyperkalemia, where normal potassium levels are 3.5 to 5.0 mEq/L.
Choice B rationale
Nasogastric suctioning involves the continuous or intermittent removal of gastric contents, including water, hydrochloric acid, and electrolytes like sodium and potassium. This process results in the loss of isotonic fluid from the extracellular compartment, putting the client at a high risk for fluid volume deficit rather than excess. Additionally, this loss can lead to metabolic alkalosis. Clients with nasogastric tubes require careful monitoring of intake and output to prevent dehydration and significant electrolyte imbalances.
Choice C rationale
Syndrome of inappropriate antidiuretic hormone involves the excessive release of ADH, which causes the kidneys to reabsorb high amounts of water regardless of serum osmolality. This leads to dilutional hyponatremia and a significant increase in total body water, resulting in fluid volume excess. Serum sodium levels in these clients often fall below the normal range of 135 to 145 mEq/L. The water retention expands the intravascular space, potentially leading to hypertension, edema, and weight gain.
Choice D rationale
Renal impairment significantly reduces the glomerular filtration rate, which is the ability of the kidneys to filter waste and excess fluid from the blood. When the kidneys cannot effectively excrete water and sodium, these substances accumulate in the systemic circulation, leading to hypervolemia. Normal creatinine levels are roughly 0.6 to 1.2 mg/dL; elevations indicate reduced function. This fluid retention can manifest as peripheral edema, pulmonary congestion, and increased blood pressure, making fluid management critical.
Choice E rationale
Heart failure occurs when the cardiac muscle cannot pump blood efficiently, leading to decreased cardiac output and subsequent activation of the renin-angiotensin-aldosterone system. This hormonal activation causes the kidneys to retain sodium and water to increase circulating volume, which the failing heart cannot handle. This cycle results in systemic and pulmonary venous congestion. Clients often present with jugular venous distention and crackles in the lungs, necessitating strict fluid restrictions and the use of diuretic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Lactulose is a synthetic sugar used primarily to treat constipation or hepatic encephalopathy. Its mechanism of action involves drawing water into the bowel and trapping ammonia in the gut to be excreted. It has no direct effect on serum potassium levels. In a patient with a potassium level of 6.8 mEq/L, which is significantly higher than the normal range of 3.5 to 5.0 mEq/L, lactulose would provide no therapeutic benefit for hyperkalemia.
Choice B rationale
Sevelamer is a phosphate binder used to treat hyperphosphatemia, commonly in patients with chronic kidney disease. It works by binding to dietary phosphorus in the gastrointestinal tract, preventing its absorption. While electrolyte imbalances often occur together in renal patients, sevelamer does not lower potassium. Using it for a potassium level of 6.8 mEq/L would be inappropriate as it does not address the life-threatening risk of cardiac arrhythmias associated with such high potassium.
Choice C rationale
Sodium polystyrene sulfonate is a cation-exchange resin specifically indicated for the treatment of hyperkalemia. It works in the intestines by exchanging sodium ions for potassium ions, which are then excreted from the body in the feces. A serum potassium level of 6.8 mEq/L is dangerously high, as the normal range is 3.5 to 5.0 mEq/L. Administering this medication helps lower the total body potassium and prevent the severe cardiac complications associated with hyperkalemia.
Choice D rationale
Darbepoetin alfa is an erythropoiesis-stimulating agent used to treat anemia, particularly in patients with chronic kidney disease or those receiving chemotherapy. It works by stimulating the bone marrow to produce more red blood cells. It has no physiological role in the regulation or excretion of potassium. Therefore, it is not an appropriate intervention for a patient presenting with a serum potassium level of 6.8 mEq/L, which requires urgent potassium-lowering therapy to ensure safety.
Correct Answer is D
Explanation
Choice A rationale
Fruity breath is a classic clinical manifestation of diabetic ketoacidosis rather than a hyperosmolar hyperglycemic state. It results from the production of acetone as a byproduct of ketone metabolism when the body breaks down fats for energy in the absence of insulin. In hyperosmolar hyperglycemic states, there is typically enough insulin present to prevent significant lipolysis and ketogenesis, so the characteristic fruity or sweet odor on the breath is absent.
Choice B rationale
A glucose level of 200 mg per dL is considered hyperglycemic but is far below the diagnostic threshold for a hyperosmolar hyperglycemic state. Normal fasting glucose is generally less than 100 mg per dL. In this specific condition, blood glucose levels typically exceed 600 mg per dL. The extreme hyperglycemia leads to severe osmotic diuresis and profound dehydration. A level of 200 mg per dL would be more consistent with routine diabetes management.
Choice C rationale
The presence of ketones in the urine is the hallmark of diabetic ketoacidosis, which involves the metabolic breakdown of fatty acids. In a hyperosmolar hyperglycemic state, the patient usually has sufficient endogenous insulin to suppress the formation of ketone bodies. Therefore, ketonuria is typically absent or only trace amounts are found. The absence of significant ketosis is a primary factor that differentiates this condition from the more acidic diabetic ketoacidosis state.
Choice D rationale
Elevated plasma osmolarity is the defining characteristic of this condition. It occurs due to extreme hyperglycemia causing a shift of water from the intracellular space to the extracellular space. Normal plasma osmolarity ranges from 275 to 295 mOsm per kg. In a hyperosmolar hyperglycemic state, the osmolarity often exceeds 320 mOsm per kg. This high concentration of solutes leads to severe cellular dehydration and significant neurological impairment in the affected client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.