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 C

Explanation

Choice A rationale:

Metabolic alkalosis is incorrect because it would present with a high pH and high HCO3, which is not the case here.

Choice B rationale:

Respiratory acidosis is incorrect because it would present with a low pH and high PaCO2, which is not the case here.

Choice C rationale:

Metabolic acidosis is correct because it presents with a low pH and low HCO3, which matches the client’s ABG results.

Choice D rationale:

Respiratory alkalosis is incorrect because it would present with a high pH and low PaCO2, which is not the case here.

A. "The list obtained from the client does not need to list medications that are not prescribed by the client's provider.”. B. "A comprehensive list of medications is provided for the client at the time of discharge.”. C. "Complete the reconciliation process one time when the client is first admitted to the hospital.”. D. "A nurse should write a verbal order in the medical record for medications the client was taking at home.”.

Correct Answer is B

Explanation

Choice A rationale:

The list obtained from the client should include all medications the client is taking, regardless of who prescribed them. This includes over-the-counter medications and supplements.

Choice B rationale:

Providing a comprehensive list of medications for the client at the time of discharge is an important component of medication reconciliation. This helps to ensure the client understands what medications they should be taking, how to take them, and why they are taking them.

Choice C rationale:

The reconciliation process should be completed at each transition of care, not just when the client is first admitted to the hospital. This is to ensure that any changes in medication are accurately documented and communicated.

Choice D rationale:

A nurse should not write a verbal order in the medical record for medications the client was taking at home without confirmation from the provider. This could lead to errors in medication administration.

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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?