Electrolytes Question #65

Question

The nurse is caring for a group of clients who are at risk for fluid volume excess. Which client should the nurse make a priority?

Answers

  1. 18 year-old with 8-year history of type I diabetes
    • Rationale:
  2. 45 year-old with second degree burns on the right calf and ankle
    • Rationale:
  3. 90 year-old client with a hip fracture
    • Rationale:
  4. 63 year-old recently diagnosed with heart failure
    • Rationale:

Overview

Explanation

The correct answer is D. The client with heart failure is the priority because the heart is not pumping enough blood which increases the risk for fluid volume overload. Type 1 diabetes, burns, and fractures do not increase the risk for fluid volume excess.

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.

Learning Outcomes

Test Taking Tip

Video Rationale