A nurse is assessing a client diagnosed with chronic renal disease for fluid volume excess. The nurse should recognize that which of the following provides a reliable measure of fluid retention?
Sodium level
Tissue edema
Urinary output
Daily weight
The Correct Answer is D
A. Sodium level: Serum sodium levels can vary and are not a direct measure of fluid retention.
B. Tissue edema: Edema is subjective and can be influenced by other conditions.
C. Urinary output: Many CKD patients have limited or no urine output despite fluid retention.
D. Daily weight: Daily weights are the most reliable non-invasive measure for fluid status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. pH 7.49, HCO₃ 24, PaCO₂ 30: Indicates respiratory alkalosis. Not consistent with AKI, which typically causes metabolic acidosis.
B. pH 7.26, HCO₃ 14, PaCO₂ 30: Reflects metabolic acidosis, expected in AKI due to accumulation of acidic waste (low pH, low bicarb), and partial respiratory compensation (low PaCO₂).
C. pH 7.49, HCO₃ 30, PaCO₂ 40: Reflects metabolic alkalosis; not expected in AKI.
D. pH 7.26, HCO₃ 24, PaCO₂ 46: Reflects respiratory acidosis (low pH, elevated CO₂), but bicarb is normal, which does not align with AKI-induced acidosis.
Correct Answer is A
Explanation
A. Skin is red, blanches, and weeps: This is consistent with deep partial-thickness burns. These burns damage deeper layers but still allow capillary refill and exudate.
B. Skin has a leathery and dry: This is characteristic of full-thickness (third-degree) burns.
C. Skin is waxy in appearance: A waxy appearance suggests full-thickness burns.
D. Skin is intact, dry, and red in color: This indicates superficial (first-degree) burns like sunburn.
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