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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 B

Explanation

Choice A rationale:

Metabolic alkalosis is characterized by a high pH (above 7.45), high bicarbonate (HCO3-) levels, and normal or low PaCO2. The patient's ABGs show a low pH (7.26), low bicarbonate (14 mEq/L), and low PaCO2 (30 mm Hg), which are not consistent with metabolic alkalosis.

Choice C rationale:

Respiratory alkalosis is characterized by a high pH (above 7.45), low PaCO2, and normal or slightly elevated bicarbonate levels. The patient's ABGs do show a low PaCO2, but the pH is low (acidic) and the bicarbonate is low, which are not consistent with respiratory alkalosis.

Choice D rationale:

Respiratory acidosis is characterized by a low pH (below 7.35), high PaCO2, and normal or slightly elevated bicarbonate levels. The patient's ABGs do show a low pH, but the PaCO2 is also low, which is not consistent with respiratory acidosis.

Rationale for the correct answer, B:

Metabolic acidosis is characterized by a low pH (below 7.35), low bicarbonate levels, and normal or low PaCO2. The patient's ABGs are consistent with metabolic acidosis because they show a low pH (7.26), low bicarbonate (14 mEq/L), and low PaCO2 (30 mm Hg).

Acute kidney injury is a common cause of metabolic acidosis. The kidneys play a vital role in regulating acid-base balance by excreting acids and reabsorbing bicarbonate. When the kidneys are damaged, they are unable to excrete acids effectively, leading to an accumulation of acids in the blood and a decrease in bicarbonate levels.

Additional Information:

It's important to note that the patient's low PaCO2 is likely a compensatory mechanism for the metabolic acidosis. In response to acidosis, the respiratory system tries to increase ventilation to blow off more carbon dioxide, which helps to raise the pH. However, this compensatory mechanism is often not enough to fully correct the acidosis.

A. Ineffective airway clearance related to thick, copious secretions. B. Impaired verbal communication related to the tracheostomy. C. High risk for infection related to surgical incisions. D. Malnourishment related to NPO Status and dysphagia.

Correct Answer is A

Explanation

Rationale for Choice A:

Ineffective airway clearance is the most immediate and life-threatening concern in the postoperative period following a radical neck dissection. This procedure involves extensive removal of lymph nodes and tissues in the neck, which can significantly disrupt normal respiratory function and airway patency. Here's a detailed explanation of the factors contributing to this risk:

Altered Respiratory Anatomy: The surgical resection of tissues and lymph nodes can directly impact the structure and function of the airway. This includes potential narrowing of the trachea, vocal cord dysfunction, and impaired laryngeal movement, all of which can hinder effective airflow.

Thick, Copious Secretions: The surgical trauma and manipulation of tissues often lead to increased production of thick, tenacious secretions in the respiratory tract. These secretions can obstruct the airway, making it difficult for the patient to clear them effectively.

Impaired Cough Reflex: The surgical dissection may disrupt the nerves involved in the cough reflex, which is a crucial mechanism for clearing secretions from the airway. This further impedes the patient's ability to maintain a patent airway.

Risk of Aspiration: Accumulation of secretions in the airway elevates the risk of aspiration, which can lead to pneumonia and other serious complications.

Potential for Edema: Postoperative swelling in the neck tissues can further compress the airway, exacerbating the risk of obstruction.

Nursing Interventions for Ineffective Airway Clearance:

Prompt recognition and management of ineffective airway clearance are essential to prevent respiratory compromise and ensure patient safety. Here are key nursing interventions that should be prioritized:

Frequent Assessment: Continuously monitor respiratory rate, effort, breath sounds, oxygen saturation, and level of consciousness for any signs of respiratory distress.

Positioning: Elevate the head of the bed to 30-45 degrees to promote lung expansion and facilitate drainage of secretions. Suctioning: Regularly suction the airway to remove secretions, using aseptic technique and proper suctioning pressure.

Deep Breathing and Coughing Exercises: Encourage and assist the patient with deep breathing and coughing exercises to mobilize secretions.

Humidification: Provide humidified oxygen or use a nebulizer to help thin secretions and make them easier to expectorate.

Chest Physiotherapy: Perform chest physiotherapy techniques, such as percussion and vibration, to loosen secretions and promote their removal.

Monitoring Fluid Balance: Maintain adequate hydration to help thin secretions, while closely monitoring fluid intake and output to prevent fluid overload.

Addressing Other Choices:

While the other choices may also be relevant concerns in the postoperative period, they do not pose the same immediate threat to life as ineffective airway clearance.

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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

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Correct Answer is B

Explanation

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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?