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","B","D"]
Explanation
A. Providing written information about the medication is important for ensuring the parents understand the treatment plan and can reference it later.
B. Discussing the potential adverse effects of the medication prepares the parents for what to monitor in their child and when to seek help.
C. Stopping the medication when the child feels better is incorrect, as it is essential to complete the full course of antibiotics to prevent resistance and recurrence of infection.
D. Explaining the reason why the child is taking the medication helps parents understand its importance and can enhance adherence to the treatment plan.
E. Advising against using a kitchen spoon for administering the medication is important, as it can lead to incorrect dosing; proper dosing devices should be used instead.
Correct Answer is D
Explanation
A. Removing nits with a fine-tooth comb is a crucial step in managing head lice to prevent re-infestation.
B. Washing bedding and clothing in hot water or sealing non-washable items helps eliminate lice and nits from the environment.
C. Soaking combs and brushes in hot water with shampoo helps ensure that any lice or nits on the grooming tools are eradicated.
D. All of the provided options are appropriate measures for managing pediculosis capitis effectively.
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