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 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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Speaking in short phrases can indicate increased effort or difficulty in breathing. While it suggests respiratory compromise, it is not an immediate concern unless it worsens or is accompanied by other severe symptoms.
B. Increased sputum production is common in clients with COPD and can indicate exacerbation or infection. It should be monitored closely but may not require immediate reporting unless it is severe or associated with other concerning symptoms.
C. This finding indicates increased respiratory effort and potential respiratory distress, which requires prompt attention and intervention.
D. A pulse oximetry reading of 90% indicates that the client's oxygen saturation is below the normal range but acceptable in client with COPD due to chronic hypoxemia.
Correct Answer is ["0.1"]
Explanation
(desired dose ÷ available concentration) = amount to administer.
For a desired dose of 5 mg and an available concentration of 50 mg/mL, the calculation would be 5 mg ÷ 50 mg/mL = 0.1 mL.
Therefore, the nurse should administer 0.1 mL per dose.
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