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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Obtain pulse oximetry every two hours: While monitoring oxygen saturation is important in assessing respiratory status, it is not a direct intervention for preventing atelectasis. It is more of an assessment tool to evaluate the effectiveness of interventions aimed at preventing atelectasis.

B. Teach the client how to use the incentive spirometer: Incentive spirometry is a valuable tool for preventing atelectasis postoperatively by promoting deep breathing and lung expansion. Teaching the client how to use the incentive spirometer and encouraging its frequent use can help maintain lung volume and prevent collapse of alveoli.

C. Instruct the client to practice abdominal breathing: While abdominal breathing can be beneficial for promoting relaxation and reducing anxiety, it is not as effective as incentive spirometry in preventing atelectasis postoperatively.

D. Encourage oral fluid intake of 2000 mL/24 hours: Adequate hydration is important for overall health and respiratory function, but it is not specifically targeted at preventing atelectasis. While hydration can help maintain airway secretions thin, it is not the primary intervention for preventing atelectasis after a lobectomy.

A. "After the surgery, I will have to be careful with heavy lifting for a few weeks." B. "I know that after the surgery, I will only have one testicle left." C. "I will have to take antibiotics as prescribed by my doctor to prevent infection." D. "I will need to avoid showering for a month after the surgery."

Correct Answer is D

Explanation

A. "After the surgery, I will have to be careful with heavy lifting for a few weeks": This statement demonstrates understanding of postoperative precautions, as heavy lifting can strain the surgical site and delay healing.

B. "I know that after the surgery, I will only have one testicle left": This statement indicates awareness of the surgical procedure and its potential outcomes, which is accurate.

C. "I will have to take antibiotics as prescribed by my doctor to prevent infection": This statement reflects understanding of the importance of antibiotic therapy to prevent postoperative infection, which is correct.

D. "I will need to avoid showering for a month after the surgery": This statement is incorrect.

Avoiding showering for a month after surgery is unnecessary and could lead to poor hygiene and potential complications such as infection. The client should be educated that showering is typically allowed after surgery, but they should avoid soaking the incision site in water until it has healed properly.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 following a left lobectomy for lung cancer. The nurse should prioritize which of the following interventions to prevent atelectasis?

Correct Answer is B

Explanation

A nurse is educating a client who was diagnosed with left testicular cancer and is scheduled for an orchiectomy. Which statement made by the client would require further teaching?

Correct Answer is D

Explanation

Identify the following Cardiac Rhythm:

A nurse caring for a client who is at home on hospice care. Exhibits At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

A nurse is caring for a client diagnosed with a pulmonary embolism that is placed on a continuous heparin infusion. The nurse should notify the health care provider for which of the following findings?

A home care visiting nurse suspects that an older adult client is developing chronic renal disease. Since the client has no history of cardiovascular disease, what data should the nurse assess further?

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?

A nurse is teaching a client diagnosed with acute renal failure about how the disease progresses. The nurse should recognize that the teaching is effective when the client can accurately identify which phases of renal disease progression? (Select all that apply.)

A student nurse is learning about client safety. The student nurse should recognize that which of the following is true regarding client safety and prevention of harm?

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?