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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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.

A. Acute hemolysis B. Disequilibrium syndrome C. Septic shock D. Air embolism

Correct Answer is B

Explanation

A. Acute hemolysis: While it is a complication of dialysis, it typically presents with back pain, dark red urine, and hypotension.

B. Disequilibrium syndrome: Caused by rapid removal of urea during dialysis, leading to cerebral edema. Early signs include nausea, headache, restlessness, and confusion.

C. Septic shock: Presents with hypotension, tachycardia, and signs of infection. Not the most likely with nausea and headache alone.

D. Air embolism: Presents with sudden chest pain, dyspnea, and hypotension; not typically with headache and restlessness alone.

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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

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