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 B

Explanation

A. People mistakenly think they are experiencing seasonal allergies: While seasonal allergies may share some symptoms with the common cold, such as nasal congestion and sneezing, they are caused by allergens rather than viruses. This factor does not directly contribute to the high communicability of the common cold.

B. The virus is spread by individuals who don't have symptoms: The common cold is highly communicable because individuals infected with the virus can spread it to others even before they develop symptoms or when they have mild symptoms. This makes it challenging to prevent the spread of the virus, as infected individuals may not realize they are contagious.

C. Hand washing is not effective against the cold virus: Hand washing is an effective measure for preventing the spread of the common cold virus. Proper hand hygiene can help reduce the transmission of the virus from contaminated surfaces to the nose and mouth.

D. Use of over-the-counter cold products reduces immune resistance: Over-the-counter cold products may help relieve symptoms of the common cold but do not directly affect immune resistance. However, reliance on symptomatic relief without taking precautions to prevent the spread of the virus can contribute to its communicability.

A. Irregular pulsations B. Bounding pulsations C. Tachycardia D. Bradycardia

Correct Answer is A

Explanation

A. Irregular pulsations: Premature ventricular contractions (PVCs) are abnormal heartbeats originating in the ventricles, causing irregularities in the heart rhythm. Auscultating the apical pulse during PVCs may reveal irregular pulsations due to the irregular timing of ventricular contractions.

B. Bounding pulsations: Bounding pulsations are typically associated with conditions such as hypertension or aortic valve regurgitation but are not specifically characteristic of PVCs.

C. Tachycardia: PVCs may occur in the setting of tachycardia, but the presence of PVCs themselves does not necessarily indicate a rapid heart rate. The rhythm may be irregular due to PVCs, but the overall heart rate may not be consistently elevated.

D. Bradycardia: PVCs are not typically associated with bradycardia. Bradycardia refers to a slow heart rate, while PVCs involve premature extra beats originating from the ventricles.

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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 clinic nurse is caring for a large number of clients diagnosed with the common cold. The nurse should recognize that which factor contributes to the high communicability of the common cold?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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