A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid imbalance?
homeostasis
fluid volume excess
Low fluid volume
fluid volume deficit
The Correct Answer is B
Renal failure can cause a buildup of fluid in the body. When kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood’s chemical makeup may get out of balance. This can lead to fluid retention, causing swelling in your legs, ankles or feet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.
Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.
While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.
Correct Answer is A
Explanation
In case of suspected ingestion of a poisonous substance, the priority response of the poison control nurse should be to assess the child's vital signs, especially breathing and heart rate, to determine if the child is experiencing any immediate life-threatening symptoms. This information will help the nurse determine the appropriate course of action, such as whether to instruct the caregiver to perform CPR or to immediately call for emergency medical assistance.
Asking about the substance ingested and the time of ingestion are also important pieces of information to gather, but they should not take priority over assessing the child's vital signs. Inducing vomiting is generally not recommended unless instructed to do so by a medical professional, as it can cause further harm if the substance ingested is corrosive or caustic.
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