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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
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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