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 B

Explanation

Choice A rationale:

Metabolic acidosis would likely present with rapid, deep breathing (Kussmaul respirations), not slow and shallow breathing.

Choice B rationale:

The client’s symptoms of vomiting (which can cause a loss of stomach acid), dizziness, palpitations, and numbness and tingling in the extremities and around the mouth are consistent with metabolic alkalosis.

Choice C rationale:

Respiratory alkalosis would likely present with rapid breathing, not slow and shallow breathing.

Choice D rationale:

Respiratory acidosis would likely present with rapid, shallow breathing, not slow and shallow breathing.

A. Decreased deep-tendon reflexes. B. Skeletal muscle weakness. C. Hypoactive bowel sounds. D. Tingling of the lips.

Correct Answer is D

Explanation

Choice A rationale:

Decreased deep-tendon reflexes are not a common symptom of hypocalcemia. Normal calcium levels in the blood range from 8.5 to 10.2 mg/dL1.

Choice B rationale:

Skeletal muscle weakness is a symptom of hypercalcemia, not hypocalcemia.

Choice C rationale:

Hypoactive bowel sounds are associated with hypercalcemia, not hypocalcemia.

Choice D rationale:

Tingling of the lips is a common symptom of hypocalcemia. This occurs due to increased excitability of the nerves.

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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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Correct Answer is B

Explanation

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Correct Answer is D

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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?