A nurse is planning care for a client with acute kidney injury. The nurse should recognize that which assessment data best supports the nursing diagnosis of Excess Fluid Volume?

Wheezing in all lung fields.

Pitting edema in bilateral lower extremities.

Oral fluid intake of 2000 mL in 24 hours.

Significant fatigue for more than one month.

Answer and Explanation

The Correct Answer is B

A.   Wheezing in all lung fields may indicate respiratory issues but does not directly support the diagnosis of Excess Fluid Volume.
B.   Pitting edema in bilateral lower extremities is a classic sign of fluid overload, which directly supports the diagnosis of Excess Fluid Volume.

C.   An oral fluid intake of 2000 mL in 24 hours is within normal limits for an adult and does not necessarily indicate Excess Fluid Volume without other symptoms.
D.   Significant fatigue for more than one month could be related to a variety of conditions and is too nonspecific to support the diagnosis of Excess Fluid Volume without additional assessment data.

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Correct Answer is A

Explanation

A. "My sense of smell is taking a long time to return.": This statement indicates a misunderstanding because, after a total laryngectomy, the sense of smell is significantly impaired or lost due to the inability to breathe through the nose. The client needs further teaching to understand that this change is likely permanent.

B. "Breathing through my stoma has diminished my sense of smell.": This statement is accurate as the stoma bypasses the nasal passages, reducing the sense of smell.

C. "I can't smell what I eat, but hope to enjoy eating in the future.": This shows an understanding that the sense of smell is impaired but expresses a positive outlook on enjoying food in other ways.

D. "I am happy to have a mild sense of taste despite no sense of smell.": This statement indicates an understanding of the sensory changes post-laryngectomy and reflects realistic expectations.

A. Isolation gown B. Contact isolation C. Standard precautions D. Respiratory isolation

Correct Answer is C

Explanation

A. Isolation gown: Isolation gowns are used as part of contact precautions or airborne precautions for specific infectious diseases that require additional transmission-based precautions beyond standard precautions. However, standard precautions are generally sufficient for caring for clients with HIV receiving antiretroviral therapy.

B. Contact isolation: Contact isolation is used for patients with known or suspected infections that can be transmitted by direct or indirect contact with the patient or their environment. HIV does not require contact isolation unless there are additional infections or conditions present that warrant contact precautions.
C. Standard precautions: Standard precautions are the basic infection prevention practices that apply to all patient care, regardless of the suspected or confirmed infection status of the patient. This includes practices such as hand hygiene, the use of personal protective equipment (e.g., gloves, gown, mask, eye protection) when indicated, and safe injection practices. Standard precautions should be used for all patients, including those with HIV, to prevent the transmission of infectious agents.
D. Respiratory isolation: Respiratory isolation is used for patients with known or suspected respiratory infections that are transmitted through respiratory droplets. HIV is not transmitted through respiratory droplets and does not require respiratory isolation.

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A nurse is planning care for a client with acute kidney injury. The nurse should recognize that which assessment data best supports the nursing diagnosis of Excess Fluid Volume?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client two months following a total laryngectomy. The nurse should recognize that which of the following statements made by the client indicates the need for further teaching?

Correct Answer is A

Explanation

A nurse is providing direction to a nursing assistant who will be caring for a client with human immunodeficiency virus (HIV) and receiving azidothymidine (AZT) antiretroviral therapy. The nurse should instruct the nursing assistant to implement which of the following actions?

Correct Answer is C

Explanation

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