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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Daily weights provide a reliable and accurate measure of ﬂuid balance in the body. An increase in weight can indicate ﬂuid retention and the need for further intervention. While daily intake and output recordings, blood pressure and heart rate checks, and CMP lab draws can also provide useful information, daily weights are the most eﬀective way to monitor for excess ﬂuid volume in this situation.

A. Perform respiratory assessment. B. Document hypoxemia. C. Check the placement of the pulse oximeter. D. Report pulse oximetry to the health care provider.

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.

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A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which ﬂuid imbalance?

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Naxlex Comprehensive Predictor Exams

A patient with congestive heart failure is at risk of excess ﬂuid volume. Which intervention will best determine if the patient is beginning to have excess ﬂuid volume?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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