A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching?
"I will put beverages in large containers to give the appearance of drinking a lot.”.
"I should consume most of the fluid during the evening.”.
"I will make a list of my favorite beverages.”.
"I will not add ice cream to the amount of fluid intake.”.
The Correct Answer is C
The correct answer is Choice C: "I will make a list of my favorite beverages."
Choice A rationale: Stating that they will put beverages in large containers to give the appearance of drinking a lot demonstrates a lack of understanding of fluid restriction guidelines. It focuses on the appearance rather than the actual fluid intake limitation. This statement does not reflect an understanding of the need to limit fluids in acute kidney disease.
Choice B rationale: Consuming most fluids during the evening is not recommended for clients with acute kidney disease as it may lead to discomfort, nighttime urination, and fluid overload. This statement does not demonstrate an understanding of the importance of spreading fluid intake throughout the day.
Choice C rationale: Making a list of favorite beverages indicates the client's understanding of fluid restrictions. This approach can help the client prioritize their preferred beverages while staying within their prescribed fluid allowance. It shows that the client is aware of the need to be selective in their fluid intake.
Choice D rationale: Although avoiding ice cream is an appropriate action due to its contribution to fluid intake, this statement alone does not necessarily indicate a comprehensive understanding of fluid restrictions. The client must also be aware of the importance of monitoring all sources of fluid intake, including other foods and beverages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Using a microwave for cooking is not a safety risk.
Choice B rationale:
Electrical cords along the walls are not a safety risk.
Choice C rationale:
Handrails in the bathroom are not a safety risk.
Choice D rationale:
Scatter rugs in the kitchen can cause falls, hence they are a safety risk.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
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Vision (Blurred)
- Interpretation: Potential worsening condition
- Rationale: Blurred vision can be a sign of lithium toxicity. Despite the lithium level improving, this symptom indicates that neurotoxicity may still be present.
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Lithium Level (1.2 mEq/L)
- Interpretation: Potential improvement
- Rationale: The lithium level has decreased from 1.8 mEq/L (toxic) to 1.2 mEq/L, which is within the therapeutic range (0.6-1.2 mEq/L). This indicates that treatment to lower lithium toxicity is effective.
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Urine Output (40 mL/hr)
- Interpretation: Potential improvement
- Rationale: A urine output of 40 mL/hr is within the acceptable range (normal is greater than 30 mL/hr), suggesting that kidney function is adequate and not compromised by lithium toxicity.
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Mucous Membranes (Pale, Dry)
- Interpretation: Potential worsening condition
- Rationale: Pale, dry mucous membranes suggest dehydration, which can increase the risk of lithium toxicity and negatively affect overall health.
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Vital Signs (BP 88/50 mm Hg, Pulse 96/min)
- Interpretation: Potential worsening condition
- Rationale: The drop in blood pressure from 130/84 mm Hg to 88/50 mm Hg indicates hypotension. This could be related to dehydration or lithium toxicity, and it requires follow-up as the condition is deteriorating.
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