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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "When the doctor comes to see you, we can talk about whether you will need a transplant." This response acknowledges the client's concerns and opens the door for further discussion with the healthcare provider about the client's prognosis and potential need for a kidney transplant. It provides an opportunity for the client to receive accurate information from the appropriate healthcare professional.
B. "Kidney transplantation is likely, and it would be a good idea to start talking to family members." This response may cause unnecessary anxiety and speculation for the client without
confirmation from the healthcare provider. It is important to provide information based on the client's specific situation and medical assessment.
C. "No, don't think that. You're going to be fine in a few weeks." This response provides false reassurance and does not address the client's concerns or the potential seriousness of acute kidney injury. It is essential to provide honest and accurate information to the client.
D. "Your condition can be reversed with prompt treatment and usually will not destroy the kidney." While acute kidney injury can sometimes be reversible with prompt and appropriate treatment, it is not always the case. Additionally, it does not address the potential need for a kidney transplant, which depends on the severity and underlying cause of the kidney injury.
Correct Answer is ["B","D","E"]
Explanation
A. Elevated temperature: Elevated temperature is not typically associated with advanced COPD unless there is an underlying infection. Infections such as pneumonia may exacerbate COPD symptoms but are not universal findings in advanced COPD.
B. Pursed-lip breathing: Pursed-lip breathing is a common compensatory mechanism seen in clients with COPD. It helps to slow down the rate of expiration and prevents alveolar collapse, improving gas exchange.
C. Clubbing of the fingers: Clubbing of the fingers is not typically associated with COPD. It is more commonly seen in conditions such as chronic hypoxemia, congenital heart disease, and certain lung diseases like bronchiectasis.
D. Concave chest: In advanced COPD, the chest may appear hyperinflated with a barrel-shaped chest due to air trapping. The presence of a concave chest is not characteristic of COPD.
E. Dyspnea at rest: Dyspnea, or difficulty breathing, is a hallmark symptom of COPD. In advanced stages, clients may experience dyspnea even at rest due to severe airflow limitation and impaired gas exchange.
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