The nursing diagnosis of Excess Fluid Volume is made for a patient with chronic kidney disease. Which of the following data is most important for the nurse to collect for this patient based on the nursing diagnosis?
daily weight
vital signs
intake and output
skin turgor
The Correct Answer is C
A. Daily weight monitoring is important for assessing fluid status but may not provide real-time information about fluid balance changes.
B. Vital signs are important for overall assessment but may not specifically address the nursing diagnosis of Excess Fluid Volume unless there are significant changes indicative of fluid overload or dehydration.
C. Monitoring intake and output provides direct information about fluid balance and renal function, helping to identify trends and assess the effectiveness of interventions aimed at managing fluid volume.
D. Skin turgor assessment is useful for evaluating hydration status but may not provide comprehensive data on fluid volume excess alone.
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Related Questions
Correct Answer is B
Explanation
A. Fatigue is a common symptom in patients with multiple myeloma but may not directly impact safety in the home environment as much as other factors.
B. An unsteady gait can increase the risk of falls and injuries, making it a priority for safety considerations in the home environment.
C. Back pain is common in multiple myeloma but may not directly affect safety in the home environment unless it significantly impairs mobility.
D. Dyspnea on exertion may limit physical activity but may not pose an immediate safety risk in the home environment unless it indicates a severe respiratory compromise.
Correct Answer is D
Explanation
A. Facial flushing is not typically associated with end-stage kidney disease and waiting for transport to dialysis. It may be indicative of other conditions such as fever, allergic reactions, or hormonal changes.
B. Hypotension is not a common finding in patients with end-stage kidney disease.
These patients often experience hypertension due to fluid overload and electrolyte imbalances.
C. Diaphoresis, or excessive sweating, is not typically associated with end-stage kidney disease and waiting for transport to dialysis. It may occur in response to other factors such as fever, pain, or anxiety.
D. Peripheral edema, or swelling in the extremities, is a common finding in patients with end-stage kidney disease due to fluid retention and impaired fluid balance regulation.
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