Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank


4. Client with chronic renal failure ANS: 2


Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third-spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal (GI) malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third-spacing.


Test-Taking Strategy: To answer this question accurately, you must be familiar with the concept and causes of third-spacing of fluids and associated disease processes. This would allow you to eliminate “client with a major burn,” “client with Laënnec’s cirrhosis,” and “client with chronic renal failure” systematically. Remember that third- space fluid is fluid that shifts into the interstitial spaces. Review the concept of third- spacing if you had difficulty with this question.


PTS: 1 DIF: Level of Cognitive Ability: Analyzing REF: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient- centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Nursing Sciences MSC: Integrated Process: Nursing Process—Assessment


14. The nurse is caring for a group of clients on the clinical nursing unit. Which of the following clients should the nurse plan to monitor for signs of fluid volume deficit? 1. Client with an ileostomy 2. Client in acute renal failure 3. Client in congestive heart failure 4. Client with controlled hypertension


ANS: 1


Rationale: The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal (GI) tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or renal failure are at risk for fluid volume excess. Hypertension is unrelated to the subject of the question.


Test-Taking Strategy: Focus on the strategic words “fluid volume deficit.” Read each option, considering the fluid imbalance that can occur in each. Eliminate “client in acute renal failure” and “client in congestive heart failure” first because these clients would be more likely to retain fluid than to lose it. Choose correctly between the remaining two


Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank


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