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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An oral rehydration solution is specifically designed to replace lost fluids and electrolytes, making it the best choice for children recovering from gastroenteritis.
B. Water alone does not provide the necessary electrolytes and may not effectively rehydrate the child.
C. Broth can provide some hydration but lacks the specific electrolyte balance found in oral rehydration solutions.
D. Diluted apple juice is not as effective for rehydration as a balanced oral rehydration solution, which is specifically formulated for this purpose.
Correct Answer is B
Explanation
A. Keeping a written document of the treatment plan is essential for ensuring continuity of care and effective communication with healthcare providers.
B. Parents should notify their provider immediately, rather than waiting for the next business day, if their child has a sore throat, as this could indicate a possible infection in an immunocompromised child.
C. Using acetaminophen is generally appropriate for managing pain or fever in children receiving chemotherapy, but it should be done with caution regarding dosage and timing.
D. Maintaining a written list of medical appointments helps keep track of the child’s care and is a good practice for managing their health.
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