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. Passing flatus every 30 minutes indicates bowel activity and suggests that the child may be able to resume oral intake.
B. Absent bowel sounds indicate a lack of gastrointestinal function, which supports the continuation of NPO status until bowel function returns.
C. An increase in abdominal girth, even by 1 cm, can be concerning postoperatively and may indicate fluid retention or other issues, warranting further assessment.
D. Pain at the operative site is expected post-surgery, but it does not directly relate to the child’s ability to resume oral intake.
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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