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 NPO status since midnight for an endoscopy.

A client who has heart failure and is receiving diuretic therapy.

A client who has gastroenteritis and is receiving oral fluids.

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

Answer and Explanation

The Correct Answer is B

The correct answer is choice B.

Choice A rationale:

A client who has NPO (nothing by mouth) status since midnight for an endoscopy could be at risk for fluid volume deficit. NPO status means the client has not been able to consume fluids orally, which could lead to a decrease in fluid intake. However, the risk is relatively low if the NPO status has only been in place since midnight and the client is otherwise healthy.

Choice B rationale:

A client who has heart failure and is receiving diuretic therapy is at a high risk for fluid volume deficit. Diuretics are used in heart failure to remove excess fluid from the body, but they can also lead to fluid volume deficit if not properly managed. This is because diuretics increase urine output, which can lead to a loss of fluid and electrolytes.

Choice C rationale:

A client who has gastroenteritis and is receiving oral fluids is not typically at risk for fluid volume deficit. Gastroenteritis can cause fluid loss through diarrhea and vomiting, but if the client is able to consume and retain oral fluids, they can usually maintain their fluid balance.

Choice D rationale:

A client who has end-stage kidney disease and will undergo dialysis could be at risk for fluid volume deficit, but this risk is typically well-managed during dialysis. Dialysis removes waste and excess fluid from the blood, and fluid intake is carefully monitored and adjusted based on the individual’s needs. Therefore, while there is a potential risk, it is usually well-controlled under the care of healthcare professionals.

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Correct Answer is D

Explanation

Choice A rationale:

Obtaining the number of the client’s provider is not the immediate action to take. The client is showing signs of a possible stroke (right-sided weakness and slurred speech), which is a medical emergency.

Choice B rationale:

Finding a location for the client to sit is not the immediate action to take. The client needs medical attention immediately due to the signs of a possible stroke.

Choice C rationale:

Driving the client to the nearest emergency room is not the best action to take. It would be faster and safer to call emergency medical services who are trained to handle such situations.

Choice D rationale:

Calling emergency medical services is the correct action. The client is showing signs of a possible stroke, which requires immediate medical attention.

A. Pulmonary vein. B. Pulmonary artery. C. Aorta. D. Inferior vena cava.

Correct Answer is C

Explanation

Choice A rationale:

This statement is incorrect because the pulmonary vein carries oxygenated blood from the lungs to the left atrium, not from the left ventricle.

Choice B rationale:

This statement is incorrect because the pulmonary artery carries deoxygenated blood from the right ventricle to the lungs, not from the left ventricle.

Choice C rationale:

This statement is correct. When the left ventricle contracts, it pushes blood through the aortic semilunar valve into the aorta, the largest artery in the body.

Choice D rationale:

This statement is incorrect because the inferior vena cava carries deoxygenated blood from the lower half of the body to the right atrium, not from the left ventricle.

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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?

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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?