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
The Correct Answer is D
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. NPO (nothing by mouth) status for procedures such as endoscopy prevents oral intake of fluids and food. Depending on the duration of NPO status and the client's baseline fluid needs, prolonged restriction can lead to dehydration and fluid volume deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Body weight is one of the most reliable indicators of fluid status in a dialysis patient. Before and after each hemodialysis session, the nurse should weigh the client using the same scale under similar conditions (e.g., same clothing). The difference in weight reflects fluid loss during the dialysis treatment. This measurement helps guide adjustments in fluid management and dialysis prescriptions.
B. Abdominal girth can increase due to fluid accumulation in the abdomen (ascites) but is less specific for measuring fluid losses during dialysis. It may be more indicative of fluid retention over a longer period rather than immediate changes related to a single dialysis session.
C. Neck vein distention can be a sign of fluid overload but is not typically used to assess fluid losses during dialysis. It may be more relevant for assessing fluid status over time rather than immediate changes post- dialysis.
D. Blood pressure can fluctuate based on various factors, including fluid status. While blood pressure monitoring is essential in dialysis patients, it alone does not reliably reflect fluid losses during dialysis sessions.
Correct Answer is B
Explanation
A. Gelatin is derived from collagen obtained from various animal body parts. It is commonly used in medications, including some capsules and intravenous (IV) preparations. It has no association with cardiac catheterization procedure.
B. This is because the contrast dye used during the procedure typically contains iodine, which can cause an allergic reaction in susceptible individuals.
C. Yeast allergies are reactions to proteins found in yeast, commonly used in baking and brewing and sometimes present in vaccines and medications. However, it has no association with cardiac catheterization procedure.
D. Egg allergies involve reactions to proteins found in eggs and can be present in vaccines, some medications, and some foods. However, it has no association with cardiac catheterization procedure.
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