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 D
Explanation
A. Administering an IV bolus medication does not typically require gowning unless there is a risk of exposure to bodily fluids.
B. Talking to the client does not necessitate wearing a gown, as it does not pose a risk of exposure.
C. Administering an IM injection may require gloves but not necessarily a gown unless there is a risk of splashing.
D. Completing a dressing change involves potential exposure to bodily fluids, so wearing a gown is appropriate for infection control.
Correct Answer is ["C","D"]
Explanation
A. Frequent, thorough handwashing is essential to prevent infection, especially for immunocompromised children.
B. Having the child sleep in a separate bed and room may help minimize exposure to pathogens from family members.
C. Encouraging frequent close contact with visitors increases the risk of infections and should be avoided.
D. Fresh flowers and plants can harbor bacteria and should be avoided in the environment of an immunocompromised child.
E. Protecting the central venous access device is vital to prevent infections; this practice should be emphasized.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.