A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

Sodium level.

Tissue turgor.

Daily weight.

Intake and output.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Sodium level is a laboratory parameter that can be helpful in assessing fluid balance, but it does not directly measure fluid retention. Abnormal sodium levels may indicate fluid imbalances, but it is not the most reliable measure of fluid retention.

Choice B rationale:

Tissue turgor refers to the skin's elasticity, and it can be used to assess dehydration rather than fluid retention. Poor turgor may indicate dehydration, but it does not specifically measure fluid volume increase.

Choice C rationale:

Daily weight is a reliable measure of fluid retention. An increase in weight over a short period may indicate fluid accumulation in the body, while a decrease in weight could signify fluid loss. It is essential to monitor weight consistently under standardized conditions (e.g., same time, same clothing) for accurate assessment.

Choice D rationale:

Intake and output records provide information about fluid intake and output but may not always reflect fluid retention accurately. It is helpful for assessing fluid balance, but daily weight is a more direct and reliable measure of fluid retention.

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Correct Answer is B

Explanation

Other electrolyte disturbances.

Choice A rationale:

Drug toxicity is not directly related to hypocalcemia. The main concern in hypocalcemia is the calcium imbalance itself, not drug toxicity.

Choice B rationale:

Other electrolyte disturbances should be assessed because imbalances in other electrolytes, such as potassium and magnesium, are often associated with hypocalcemia. Electrolyte imbalances can interact and exacerbate each other, potentially leading to more severe complications.

Choice C rationale:

Hypertension is not a typical assessment finding in hypocalcemia. Hypertension is not directly related to calcium levels but may have other underlying causes.

Choice D rationale:

Visual disturbances are not commonly associated with hypocalcemia. Hypocalcemia is more likely to present with neuromuscular and cardiovascular symptoms, rather than visual disturbances.

A. Add the ordered dose to the IV hanging. B. Administer the dose IV push over 3 minutes. C. Monitor the injection site for redness. D. D. Use an infusion controller for the IV. E. Monitor fluid intake and output.

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

Explanation

The correct answer is choiceC. Monitor the injection site for redness,D. Use an infusion controller for the IV, andE. Monitor fluid intake and output.

Choice A rationale:

Adding the ordered dose to the IV hanging is incorrect because potassium chloride should never be added to an already hanging IV solution due to the risk of uneven distribution and potential overdose.

Choice B rationale:

Administering the dose IV push over 3 minutes is incorrect because potassium chloride should never be given by direct IV injection.It must always be diluted and administered slowly to prevent cardiac complications.

Choice C rationale:

Monitoring the injection site for redness is correct because potassium chloride can cause irritation and phlebitis at the injection site.

Choice D rationale:

Using an infusion controller for the IV is correct because it ensures the potassium chloride is administered at a controlled rate, reducing the risk of rapid infusion and potential cardiac issues.

Choice E rationale:

Monitoring fluid intake and output is correct because it helps assess the patient’s overall fluid balance and detect any signs of fluid overload or deficit, which is crucial when administering potassium.

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A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with hypocalcemia. What additional assessments should the nurse include when caring for this patient?

Correct Answer is B

Explanation

The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.

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

Explanation

A patient experiencing multisystem fluid volume deficit has tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?

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