Electrolytes Question #50
The nurse is assigned a group of clients. Which client should the nurse identify as being most at risk for fluid volume deficit?
- A client with vomiting and diarrhea for 48 hours
- A client with wet-to-dry dressings
- A client with heart failure
- A client with bounding neck veins
The correct answer is A. A client who is vomiting and has diarrhea for 48 hours is most likely at risk for fluid volume deficit due to the loss of fluids and potential for dehydration. The client will also be losing electrolytes through both the vomiting and diarrhea, which will contribute to a fluid volume deficit. The client receiving wet-to-dry dressings may have fluid absorbed through the wound bed. A client with heart failure is most at risk for fluid volume overload. Bounding neck veins is a sign of fluid volume overload.
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.