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 D
Explanation
Formula: 4 mL × Body weight (kg) × %TBSA
4 × 100 × 40 = 16,000 mL total in 24 hours
Half (8,000 mL) is given in the first 8 hours
Answer- 8000ml
Correct Answer is B
Explanation
A. Place the drainage bag above the level of the client's abdomen: This would impede drainage by gravity. The drainage bag should be below abdominal level to promote outflow.
B. Warm the dialysate solution prior to instillation: Warming the solution enhances diffusion, promotes comfort, and prevents abdominal cramping. Use a warming pad, not a microwave.
C. Monitor vital signs every 2 hours during the procedure: While vital signs are monitored, more frequent monitoring is often required during the initial phase or if the patient is unstable.
D. Maintain the client in a left lateral position during dialysis: The semi-Fowler’s position is preferred to facilitate flow and lung expansion, not lateral positioning.
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