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

Answer and Explanation

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.

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Free Nursing Study Resources

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.

A. Auscultate the antecubital fossa using a Doppler stethoscope. B. Measure the client's blood pressure to ensure it is higher in the left arm than the right. C. Auscultate the site for a bruit. D. Check the brachial and radial pulses of the left arm simultaneously.

Correct Answer is C

Explanation

A. Auscultate the antecubital fossa using a Doppler stethoscope: The graft is located in the forearm, not the antecubital fossa.

B. Measure the client's blood pressure to ensure it is higher in the left arm than the right: This does not assess AV graft patency and blood pressure should be avoided in the arm with a graft.

C. Auscultate the site for a bruit: The presence of a bruit and thrill indicates blood flow through the graft, confirming patency.

D. Check the brachial and radial pulses of the left arm simultaneously: While peripheral pulses can offer some insight, they do not directly confirm graft patency.

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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?

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Naxlex Comprehensive Predictor Exams

A child has presented to the ER after a burn injury from a hot soup spill. Exhibits A nurse is caring for a preschooler diagnosed with a superficial partial- thickness burn on the right forearm. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

Correct Answer is C

Explanation

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