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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","F"]
Explanation
A. Small bladder capacity can contribute to enuresis but may not need to be ruled out before addressing psychological factors.
B. Urinary tract infections can cause enuresis and should be evaluated and treated before investigating psychological causes.
C. Stress incontinence typically refers to the involuntary loss of urine due to pressure and may be a psychological factor rather than a physiological cause.
D. Regression can be a behavioral response but is not a medical cause that needs to be ruled out.
E. Cognitive dysfunction can contribute to enuresis but is not primarily a medical cause that needs to be ruled out.
F. Diabetes mellitus can lead to increased urination (polyuria) and should be evaluated as a potential medical cause before considering psychological factors.
Correct Answer is B
Explanation
A. While prophylactic antibiotics may be considered, they are not standard for all procedures in hemophilia management.
B. Recombinant factor VIII is essential to ensure adequate clotting during and after the extraction, minimizing the risk of bleeding complications.
C. Packed RBCs may be needed for severe anemia but are not a standard preventive measure for hemophilia management during dental procedures.
D. Fresh frozen plasma can provide clotting factors but is not the preferred treatment for hemophilia A, where specific factor VIII replacement is needed.
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