A nurse is assessing a client diagnosed with end-stage renal disease (ESRD) that is receiving hemodialysis. Which of the following findings should the nurse identify as an indication that the client is experiencing fluid overload?
Oxygen saturation 93%
Distended neck veins
The client has gained 1 pound since yesterday.
Return of skin to previous position when the client's shin is palpated
The Correct Answer is B
A. Oxygen saturation 93%:
While this is slightly below normal, it is not a definitive or specific indicator of fluid overload.
B. Distended neck veins:
Jugular vein distention is a classic sign of fluid overload and increased central venous pressure.
C. The client has gained 1 pound since yesterday:
A 1-pound weight gain could be due to fluid retention, but it's not significant enough on its own to confirm fluid overload.
D. Return of skin to previous position when the client's shin is palpated:
This indicates normal skin turgor and does not suggest fluid overload; instead, it rules out dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Blistering of area: Blisters are characteristic of superficial partial-thickness burns, involving the epidermis and part of the dermis.
B. Dry crusting surface: This is more typical of deeper burns; partial-thickness burns are moist.
C. Intact skin surface: The skin is not intact; it is damaged and blistered.
D. Blanching of wound area: Indicates intact capillary refill and superficial depth.
E. Pain at wound site: Nerve endings are exposed, making these burns very painful.
Correct Answer is ["C","D","E"]
Explanation
A. Calcium: Clients with CKD may have low calcium levels due to impaired vitamin D metabolism; calcium may need to be supplemented, not restricted.
B. Calories: Clients need sufficient calories to prevent catabolism. Calorie intake is typically maintained or increased, not restricted.
C. Phosphorus: Phosphorus builds up in CKD, leading to bone disorders and vascular calcification; must be limited.
D. Sodium: Sodium contributes to fluid retention and hypertension, which are problematic in CKD.
E. Protein: Protein intake is moderated (especially in non-dialysis clients) to reduce nitrogenous waste buildup, though dialysis clients may need more.
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