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A nurse is collecting data about the fluid status of four patients.
Which patient should the nurse identify as being at risk for fluid volume deficit?

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

A patient who has gastroenteritis and is receiving oral fluids.

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

A patient who has NPO status since midnight for an endoscopy.

Answer and Explanation

The Correct Answer is D

Rationale for Choice A:

Diuretics promote fluid loss, increasing the risk of fluid volume deficit.

Heart failure can lead to fluid retention, but diuretic therapy is often used to manage this excess fluid.

However, in this case, the patient is receiving diuretic therapy, which suggests that their fluid status is being actively managed.

Therefore, while this patient is at risk for fluid volume deficit, they are not the most likely candidate among the options presented.

Rationale for Choice B:

Gastroenteritis can lead to fluid loss through vomiting and diarrhea.

However, this patient is receiving oral fluids, which helps to replenish lost fluids and electrolytes.

As long as the patient is able to tolerate oral fluids and is not experiencing excessive fluid losses, they are not at significant risk for fluid volume deficit.

Rationale for Choice C:

End-stage kidney disease can impair the kidneys' ability to regulate fluid balance.

However, dialysis is a treatment that helps to remove excess fluid and waste products from the body.

Therefore, while this patient is at risk for fluid volume imbalances, they are receiving treatment to manage this risk.

Rationale for Choice D:

NPO status means that the patient has been instructed to have nothing by mouth. This means that the patient has not been able to consume any fluids since midnight.

Even in the absence of excessive fluid losses, this prolonged period of fluid restriction can lead to dehydration and fluid volume deficit.

Therefore, this patient is the most likely to be experiencing fluid volume deficit among the options presented.

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Correct Answer is ["A","D","E"]

Explanation

Choice A rationale:

Intravenous theophylline (aminophylline) is a bronchodilator that can be life-saving in cases of anaphylactic shock with bronchospasm. It works by relaxing the smooth muscles in the airways, allowing for increased airflow.

Anaphylactic shock can cause severe bronchospasm, which can lead to respiratory failure and death. Theophylline can help to reverse bronchospasm and improve oxygenation.

The dosage of theophylline should be individualized based on the patient's weight and severity of bronchospasm. It is important to monitor the patient's heart rate and blood pressure while administering theophylline, as it can cause tachycardia and arrhythmias.

Choice B rationale:

Culturing the site of the bee sting and administering antibiotics is not appropriate in the acute management of anaphylactic shock. Anaphylaxis is an allergic reaction, not an infection. Antibiotics will not address the underlying cause of the reaction.

Antibiotics may be necessary if the patient develops a secondary infection at the site of the bee sting. However, this is not a priority in the acute setting.

Choice C rationale:

Providing sips of water to moisten the mouth and throat is not a priority in the acute management of anaphylactic shock. The patient's primary concern is likely to be difficulty breathing.

If the patient is able to drink, it is important to ensure that they are able to do so safely without compromising their airway. However, this is not a life-saving intervention.

Choice D rationale:

Diphenhydramine (Benadryl) is an antihistamine that can help to block the effects of histamine, one of the chemicals released during an allergic reaction. This can help to reduce symptoms such as swelling, itching, and hives.

Diphenhydramine can also help to prevent further release of histamine, which can help to stop the progression of the allergic reaction.

Diphenhydramine is available over-the-counter, but it is important to consult a healthcare professional before administering it to a patient in anaphylactic shock.

Choice E rationale:

Surgical management of the airway may be necessary if the patient's airway becomes compromised due to swelling. This could include intubation or a tracheostomy.

It is important to be prepared for surgical airway management in case it is needed. Early preparation can help to prevent delays in treatment and improve the patient's chances of survival.

A. Request NPO status for the client. B. Elevate the head of the bed to high Fowler’s. C. Measure the client’s temperature. D. Check the client’s respiratory rate and lung sounds.

Correct Answer is D

Explanation

NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.

Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.

It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.

Rationale for Choice B:

Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.

Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.

Rationale for Choice C:

Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.

While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.

The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:

Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.

Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate

Crackles in the lungs Shortness of breath Hypoxia

Early identification of these signs is crucial for prompt intervention and prevention of serious complications.

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A nurse is collecting data about the fluid status of four patients.Which patient should the nurse identify as being at risk for fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What are the appropriate interventions for a patient experiencing anaphylactic shock from a bee sting? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

During a shift change report, a nurse notices that a patient’s IV bag of 0.9% sodium chloride has 900 mL of fluid remaining.The nurse checks again 30 minutes later and finds that the IV bag is empty. What should the nurse do in this situation?

Correct Answer is D

Explanation

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A nurse is collecting data about the fluid status of four patients.
Which patient should the nurse identify as being at risk for fluid volume deficit?