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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Narcotics are not known to directly cause hypokalemia. Their main effects are related to pain relief and central nervous system depression.
Choice B rationale:
Thiazide diuretics can cause potassium loss in the urine, leading to hypokalemia. These diuretics work by inhibiting sodium reabsorption in the distal convoluted tubule, which can lead to potassium excretion as well.
Choice C rationale:
Corticosteroids can cause sodium and water retention but are not typically associated with significant potassium abnormalities.
Choice D rationale:
Muscle relaxers are not known to cause hypokalemia. They primarily act on the neuromuscular junction and do not directly impact potassium levels.
Correct Answer is D
Explanation
The correct answer is choice D: Reduction of T-wave amplitude.
Choice A rationale:
The amplitude of the QRS complex is not directly affected by changes in serum potassium levels. It represents ventricular depolarization, and its restoration would not be an expected outcome of polystyrene sulfonate treatment
Choice B rationale:
Shortening of the P-wave duration is not an expected change with polystyrene sulfonate treatment. The P-wave represents atrial depolarization, which is not significantly impacted by the administration of this medication
Choice C rationale:
Widening of the QRS complex is associated with high serum potassium levels. The goal of polystyrene sulfonate treatment is to lower potassium levels and, thus, return the QRS complex to its normal width
Choice D rationale:
Polystyrene sulfonate aims to reduce serum potassium levels. When effective, this should result in a reduction of T-wave amplitude, which is a common ECG change seen with hyperkalemia
In conclusion, choice D is the correct answer, as a reduction in T-wave amplitude would be the expected change on the client's ECG if polystyrene sulfonate effectively lowers their serum potassium level.
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