A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

A client who has end-stage kidney disease who will undergo dialysis

A client who has gastroenteritis and is receiving oral fluids

A client who has heart failure and is receiving diuretic therapy

A client who has NPO status since midnight for an endoscopy

Answer and Explanation

The Correct Answer is B

A.   Clients with end-stage kidney disease often have impaired kidney function, leading to decreased urine output and retention of fluid and waste products. Dialysis is intended to remove excess fluid and waste from the body.
B.   Gastroenteritis involves inflammation of the gastrointestinal tract, leading to symptoms such as diarrhea and vomiting. These symptoms result in significant fluid loss.
C.   Heart failure can lead to fluid retention and edema due to the heart's inability to pump effectively. Diuretic therapy is commonly prescribed to manage fluid overload by increasing urine output. However, excessive diuresis or inadequate intake of fluids can lead to fluid volume deficit, particularly if the client does not compensate with adequate oral intake.

D.   This client has been NPO only since midnight (about 9–14 hours, depending on procedure time). While intake is restricted, this short period is not usually enough to cause a significant fluid volume deficit, unless prolonged.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Lactose intolerance does not directly increase the risk of aspiration. It is a condition where the body cannot easily digest lactose, a type of sugar found in dairy products, leading to gastrointestinal symptoms such as bloating, diarrhea, and gas. Aspiration risk is not typically associated with lactose intolerance.
B. Clients who have had a stroke often experience dysphagia (difficulty swallowing) due to impaired coordination of the muscles involved in swallowing. This dysphagia can lead to food or liquids entering the airway instead of the esophagus, increasing the risk of aspiration.
C. Prolonged diarrhea does not directly increase the risk of aspiration during eating. Diarrhea is a gastrointestinal symptom that typically affects the lower digestive tract and is not directly related to swallowing or aspiration risk.
D. After surgery, especially under general anesthesia, clients may have impaired protective airway reflexes and reduced consciousness level, increasing the risk of aspiration. The recovery phase postoperatively is critical, as clients may not have regained full control of their swallowing reflexes.
E. Radiation therapy in the head and neck region can cause tissue damage, including to the muscles and nerves involved in swallowing. This damage can result in dysphagia and increase the risk of aspiration during eating.

A. Baked potato with sour cream B. Fruit salad and carrot sticks C. Bagel with cream cheese D. Peanut butter and jelly with enriched bread

Correct Answer is D

Explanation

A. Sour cream is a dairy product, providing protein. This option provides protein from the sour cream, which is suitable for a vegetarian who consumes dairy products.
B. Fruits and vegetables generally do not provide significant protein. While fruits and vegetables are nutritious, they do not provide sufficient protein for a meal, especially for someone who is vegetarian and needs adequate protein sources.
C. Cream cheese is a dairy product that provides protein. This option also provides protein from the cream cheese, which is suitable for a vegetarian who consumes dairy products.
D. Peanut butter is a plant-based protein source and enriched bread provides carbohydrates. Peanut butter is a good source of protein for vegetarians and is a suitable option for the adolescent client who does not like beans.

View Question and Answer

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

A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk for aspiration while eating? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is assisting an adolescent client in the selection of complementary protein sources on the lunch menu. The client is a vegetarian who eats milk products but does not like beans. Which of the following food items should the nurse recommend?

Correct Answer is D

Explanation

An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

A nurse is preparing to administer haloperidol 5 mg IM to a client. Available is haloperidol 50 mg/mt. How many mt should the nurse administer per dose? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is preparing to administer dexamethasone 3 mg PO. Available is dexamethasone 5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

While admitting a client for a cardiac catheterization, the nurse asks the client about allergies. Which of the following client food allergies should the nurse report to the provider prior to the procedure?

A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed- suction drains in place. Which of the following interventions should the nurse include in the plan?

A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?

A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis?