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 A

Explanation

Choice A rationale:

The medication should be dropped into the conjunctival sac, which is the space between the lower eyelid and the eyeball. This is the correct method for administering ophthalmic drops.

Choice B rationale:

The eyedropper should not touch any part of the eye, including the sclera, to avoid contamination and potential infection.

Choice C rationale:

It is not necessary to don sterile gloves when administering ophthalmic drops. Clean gloves or hand hygiene is sufficient.

Choice D rationale:

Rubbing the eye after instilling medication can cause irritation and may disperse the medication, reducing its effectiveness.

A. Asking any part of the prescription that is unclear or inappropriate. B. Repeat the prescription back to the provider. C. Transcribe the prescription into the client's medical record. D. Obtain the provider's signature within 48 hours.

Correct Answer is A

Explanation

Choice A rationale:

The prescription should be clear and appropriate. If there is any part of the prescription that is unclear or inappropriate, it should be clarified with the provider. This is to ensure the safety and effectiveness of the medication for the client.

Choice B rationale:

Repeating the prescription back to the provider is a good practice to confirm the accuracy of the prescription. However, it is not the only step in ensuring the appropriateness of the prescription.

Choice C rationale:

Transcribing the prescription into the client’s medical record is important for documentation and continuity of care. However, it does not directly address the appropriateness of the prescription.

Choice D rationale:

Obtaining the provider’s signature within 48 hours is a regulatory requirement in some settings. However, it does not directly address the appropriateness of the prescription.

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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?