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. Carrying an EpiPen is essential for children with peanut allergies in case of anaphylaxis.
B. This statement indicates a misunderstanding; parents should notify emergency services and seek immediate medical care after using the EpiPen, not just notify the physician's office the next business day.
C. Informing the school nurse about the child’s allergy is crucial for ensuring safety while at school.
D. Having a medical alert bracelet is a wise choice for quickly informing others of the child's allergy in emergencies.
Correct Answer is ["A","B","D","E"]
Explanation
A. Washing hands frequently is important for preventing infections, which can trigger a sickle cell crisis.
B. Cold weather can cause blood vessels to constrict, increasing the risk of a sickle cell crisis, making this statement correct.
C. Restricting fluids during illness is not advisable; staying hydrated is crucial for preventing sickle cell crises.
D. Carrying a water bottle encourages adequate hydration, which is essential for individuals with sickle cell anemia to help prevent crises.
E. Taking medications as directed is vital for managing sickle cell disease and preventing complications.
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