NCLEX PN Exam Practice Test Practice Question
The nurse is caring for an adult who is admitted with severe nausea, vomiting, and diarrhea. During the last eight hours, the client has had 1000 mL of IV fluids and 100 mL of fluid from ice chips. The client has vomited a total of 600 mL and had four large diarrheal stools. The urine output for the last eight hours is 350 mL. The best interpretation of these data is that the client:
Correct Answer: C
Rationale: The data indicates that the client has lost a significant amount of fluid through vomiting (600 mL) and diarrhea (approximately 800 mL, assuming each large stool is around 200 mL), totaling 1400 mL of fluid loss. With only 1100 mL of fluid intake (1000 mL IV + 100 mL from ice chips) and a urine output of 350 mL, the client is at a net loss of fluids, indicating a risk for dehydration.
Option A is incorrect as the fluid balance is negative, not appropriate. Option B is misleading; while 350 mL may seem normal, given the client's losses, it is inadequate. Option D is also incorrect; the client is losing more fluid than they are taking in, which does not indicate fluid overload.
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