Level of Cognitive Ability - Anaysis EXAM ELABORATION

1. A nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for deficient fluid volume? * a) A client with a colostomy b) A client with congestive heart failure c) A client with decreased kidney function d) A client receiving frequent wound irrigations R: Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume. 2. A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? a) Lung congestion b) Decreased hematocrit c) Increased blood pressure * d) Decreased central venous pressure (CVP) R: Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP. The assessment findings in options 1, 2, and 3 are seen in a client with excess fluid volume. 3. A nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for excess fluid volume? a) The client taking diuretics * b) The client with renal failure c) The client with an ileostomy d) The client who requires gastrointestinal suctioning R: The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume. 4. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? a) Weight loss b) Flat neck and hand veins * c) An increase in blood pressure d) A decreased central venous pressure (CVP) R: Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. Options 1, 2, and 4 identify signs noted in deficient fluid volume. 5. A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client was at risk for developing the potassium deficit because the client: a) Has renal failure. * b) Requires nasogastric suction. c) Has a history of Addison’s disease. d) Is taking a potassium-sparing diuretic.