The home health care nurse is visiting a child with renal failure undergoing continuous ambulatory peritoneal dialysis (CAPD). Which of the following would lead the nurse to identify a nursing diagnosis of fluid overload related to CAPD?

poor skin turgor

shortness of breath

Redness at the tube insertion site

Fever

Answer and Explanation

The Correct Answer is B

A. Poor skin turgor typically indicates dehydration, not fluid overload.

B. Shortness of breath can be a sign of fluid overload, particularly in children with renal failure, as excess fluid can accumulate and lead to pulmonary edema.

C. Redness at the tube insertion site may indicate infection but does not specifically relate to fluid overload.

D. Fever is a sign of infection or inflammation and does not directly indicate fluid overload.

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Correct Answer is B

Explanation

A. Positioning for comfort is a common intervention during a vaso-occlusive crisis to alleviate pain.

B. Restricting fluid intake is contraindicated in vaso-occlusive crisis; hydration is crucial to help reduce sickling and improve circulation.

C. Avoiding strain on painful joints is appropriate to prevent exacerbating pain and potential damage.

D. Applying nasal oxygen at 2 liters may be indicated to ensure adequate oxygenation, especially if the child is experiencing any respiratory distress.

A. Replace fluids orally B. Administer antibiotics as prescribed C. Obtain a specimen for complete blood co D. Obtain urinalysis

Correct Answer is B

Explanation

A. While fluid replacement is important, in a toxic-appearing child, oral fluids may not be safe or adequate due to potential dehydration and risk of worsening condition.

B. Administering antibiotics is the priority action because the child shows signs of potential serious infection, and timely antibiotic treatment is crucial in young infants who may quickly deteriorate.

C. Obtaining a specimen for a complete blood count is necessary for diagnosing infection but is not as urgent as administering antibiotics.

D. While obtaining a urinalysis may help identify a urinary tract infection, it is not the immediate priority compared to starting antibiotic therapy.

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The home health care nurse is visiting a child with renal failure undergoing continuous ambulatory peritoneal dialysis (CAPD). Which of the following would lead the nurse to identify a nursing diagnosis of fluid overload related to CAPD?

Nursing Test Bank

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