NCLEX-RN

Category - Basic Care

A nurse is assigned to care for 4 clients during the shift. On planning nursing care, which client is at risk for fluid volume excess?
  1. An adult client with a body temperature of 103.1°F and a respiratory rate of 35 breaths per minute
  2. A client requiring wound irrigations every 3 hours
  3. A client with salmonellosis
  4. A client with a draining fistula
Explanation
Answer: B - A client requiring wound irrigations every 3 hours is at risk for fluid volume excess. Fever with an increased respiratory rate, diarrhea, and a draining fistula can increase the risk of fluid deficit. Salmonellosis is a foodborne disease that is usually manifested with diarrhea, fever, and abdominal cramps.
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