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 D

Explanation

A. Client develops petechiae on the arms, legs, and abdomen: Petechiae can indicate thrombocytopenia, which may be a complication of heparin therapy but is not an urgent concern unless severe or associated with bleeding.

B. Health care provider orders Coumadin 2.5 mg P.O. to begin today: Coumadin (warfarin) is often initiated as a bridge therapy or overlap with heparin therapy in pulmonary embolism management. This order is not necessarily inappropriate and may be part of the treatment plan.

C. Client develops slight ecchymosis at the venipuncture site: Ecchymosis at the venipuncture site can occur due to minor trauma during the insertion of IV lines or blood draws and is not necessarily indicative of a complication requiring immediate notification of the healthcare provider.

D. Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds: A significantly elevated PTT indicates a potential overdose of heparin, putting the client at risk of bleeding complications. This finding warrants immediate notification of the healthcare provider for further evaluation and possible adjustment of heparin therapy.

A. Sterilize dishes before using. B. Maintain good hygiene. C. Cook meats and fish well. D. Avoid consuming raw foods. E. Wash hands frequently

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

Explanation

A. Sterilize dishes before using: This is not typically necessary. Washing dishes with hot water and soap or using a dishwasher is sufficient to ensure they are clean.

B. Maintain good hygiene: Good hygiene practices are crucial for immunocompromised individuals to prevent infections.

C. Cook meats and fish well: Properly cooking meats and fish helps to kill any harmful bacteria and parasites that could cause infections.

D. Avoid consuming raw foods: Raw foods, especially meats, eggs, and some vegetables, can harbor harmful bacteria and parasites, posing a risk of infection.

E. Wash hands frequently: Frequent handwashing is one of the most effective ways to prevent the spread of infections.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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