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 B
Explanation
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.
Correct Answer is C
Explanation
A. Weight loss may occur with acute exacerbations but is not a guaranteed effect of prednisone therapy.
B. Prednisone does help reduce inflammation but does not directly relieve abdominal cramping; this statement may reflect a misunderstanding of its action.
C. This statement indicates a clear understanding of the need for gradual tapering of prednisone to prevent withdrawal symptoms and rebound exacerbation.
D. Noticing some medication in the stool is not a common or expected effect of prednisone and may indicate a misunderstanding of how the drug works.
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