Electrolytes Question #3
A nurse is assigned to care for a group of clients. After reviewing the medical records, which client should the nurse determine is at risk for deficient fluid volume?
- A client with a colostomy
- A client with heart failure
- A client with decreased kidney function
- A client receiving frequent wound irrigations
The correct answer is A. Colostomy can result in the loss of gastrointestinal (GI) fluids, which predisposes the client to dehydration and a variety of electrolyte disturbances. When the colostomy bag is put in place, it is possible that the fluids may not be absorbed from the stools. Heart failure and decreased kidney function increase the client’s risk of fluid volume overload. Frequent wound irrigations would not increase the client’s risk for a fluid volume deficit.
NCLEX TIP: Using critical thinking is recommended when reading priority questions. Recognizing key words in the answer choices will allow you to know how to choose the correct answer for the question. Go through each answer choice and decide is it: Maslow’s hierarchy, safety related, or following the nursing process (ADPIE). Never complete a nursing action that is outside the scope of practice.