Free Trial #10
The nurse reviews the medical records for a group of assigned clients. Which client should the nurse identify as being at risk for excess fluid volume?
- The client taking diuretics
- The client with renal failure
- The client with an ileostomy
- The client who requires gastrointestinal suctioning
The correct answer is B. Excess fluid volume is caused by decreased kidney (renal) function, congestive heart failure, the use of hypotonic fluids, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. Clients taking diuretics, with an ileostomy, or require gastrointestinal suctioning are at risk for deficient fluid volume.
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.
Test Taking Tip