A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?

The client has had a 3 lb weight gain since yesterday.

Flattened neck veins

Oxygen saturation 93%

Return of skin to previous position when the client's shin is palpated

Answer and Explanation

The Correct Answer is A

A 3 lb weight gain in a short period, especially overnight, is indicative of fluid overload in a client with end-stage kidney disease receiving hemodialysis. Hemodialysis is performed to remove excess fluid and waste products from the body. If the client is experiencing fluid overload, it means that their body is retaining more fluid than it should, and this can lead to complications such as pulmonary edema, heart failure, and other cardiovascular problems. The nurse should identify this finding as an indication of potential fluid overload and report it to the healthcare provider for further evaluation and intervention.

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Correct Answer is B

Explanation

Chronic kidney disease (CKD) is a condition where the kidneys are damaged or unable to filter blood effectively over time, leading to a gradual loss of kidney function. Several risk factors can increase the likelihood of developing CKD, and among them, diabetes and hypertension are the most common.

Diabetes is a significant risk factor for developing CKD. It can cause damage to the small blood vessels in the kidneys, impairing their ability to filter waste and fluid from the blood properly. Native Americans, along with other racial and ethnic minorities, are at a higher risk of developing diabetes compared to the general population.

While hypertension (high blood pressure) is also a risk factor for CKD, diabetes carries a higher risk. However, it's important to note that hypertension is often a comorbidity associated with CKD and can further worsen kidney function when present.

The other options listed (a 50-year-old white female with hypertension, a 40-year-old Hispanic female with cardiovascular disease, and a 28-year-old African American female with a urinary tract infection) are also at risk for CKD, but the 61-year-old Native American male with diabetes is at the highest risk based on the information provided. All patients should be educated about preventive measures to protect their kidney health, but special attention should be given to individuals with diabetes due to its significant impact on kidney function.

A. Lung sounds B. Facial swelling C. Level of anxiety D. Intake and output

Correct Answer is A

Explanation

In a patient with acute decompensated heart failure (ADHF), the priority nursing assessment is to auscultate lung sounds. ADHF is characterized by the sudden worsening of heart failure symptoms, which may include pulmonary congestion and fluid accumulation in the lungs. Assessing lung sounds helps to identify signs of pulmonary edema, which is a serious complication of ADHF.

The nurse should listen for crackles or rales, which are abnormal lung sounds caused by the presence of fluid in the alveoli. These findings suggest that the patient is experiencing fluid overload and inadequate gas exchange in the lungs. Prompt recognition of pulmonary edema allows for early intervention, such as administering diuretics or other medications, to relieve fluid overload and improve respiratory function.

While the other options (B) Facial swelling, (C) Level of anxiety, and (D) Intake and output, are important assessments in a patient with heart failure, they are not the priority in a patient with manifestations of acute decompensated heart failure. The priority is to assess for signs of respiratory

distress and pulmonary congestion, as these can quickly lead to respiratory failure and life threatening complications.

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A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?

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Naxlex Comprehensive Predictor Exams

Which patient is most likely to develop chronic kidney disease (CKD) and should be taught preventive measures by the nurse?

Correct Answer is B

Explanation

The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment?

Correct Answer is A

Explanation

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