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
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.
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