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 D

Explanation

Extracellular fluid deficit.

Choice A rationale:

Intracellular fluid deficit is a decrease in the fluid inside the cells, which may occur in conditions such as diabetic ketoacidosis. Severe burns are more likely to cause extracellular fluid shifts rather than intracellular fluid deficits.

Choice B rationale:

Interstitial fluid deficit involves a decrease in fluid in the interstitial spaces between cells. While burns can lead to fluid shifts, the primary concern is fluid loss from the vascular space (extracellular fluid).

Choice C rationale:

Intracellular fluid overload is not a typical health problem associated with severe burns. Burn injuries are more likely to cause fluid loss and shifts out of the intracellular space.

Choice D rationale:

Severe burns can result in significant loss of plasma and extracellular fluid, leading to hypovolemia and extracellular fluid deficit. This fluid loss can lead to hypovolemic shock and other complications if not adequately managed.

A. Hypocalcemia. B. Hypernatremia. C. Hyperkalemia. D. Potential Condition. Action to Take 1: Prepare to check a serum albumin level. Action to Take 2: Request a STAT ECG. Parameters to Monitor 1: Serum bicarbonate level. Parameters to Monitor 2: Intake and Output.

Correct Answer is A

Explanation

Hypocalcemia. Action to Take 1: Prepare to check a serum albumin level.

Rationale:

Hypocalcemia can be influenced by changes in serum albumin levels, as calcium may bind to albumin. Correcting calcium levels based on albumin can help determine the actual calcium status. Action to Take 2: Request a STAT ECG. Rationale: Hypocalcemia can lead to prolonged QT intervals on an electrocardiogram (ECG). A STAT ECG is necessary to assess cardiac function and detect any potential arrhythmias. Parameters to Monitor 1: Serum bicarbonate level. Rationale: Monitoring serum bicarbonate levels can help assess the client's acid-base balance and metabolic status. Abnormal bicarbonate levels may indicate metabolic disturbances. Parameters to Monitor 2: Intake and Output. Rationale: Monitoring intake and output is essential to evaluate the client's fluid balance and kidney function. Hypocalcemia can impact renal function, and assessing urine output is crucial.

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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 planning care for a patient with severe burns. What health problem should the nurse realize that this patient could develop?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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