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 ["C","D","E"]
Explanation
A. Digoxin typically decreases the heart rate by increasing vagal tone and reducing conduction through the atrioventricular node.
B. Digoxin may have minimal effects on blood pressure, primarily by improving cardiac output in patients with heart failure, but its primary action is on cardiac contractility and rhythm.
C. Digoxin has a negative chronotropic effect, meaning it slows the heart rate by increasing parasympathetic tone and decreasing conduction through the atrioventricular node.
D. Digoxin has a positive inotropic effect, meaning it increases the force of cardiac contractions, which can be beneficial in patients with heart failure.
E. Digoxin can suppress ectopic beats (abnormal heart rhythms originating outside the sinoatrial node) by slowing conduction through the atrioventricular node and enhancing vagal tone
Correct Answer is D
Explanation
A. Heat application may provide comfort for localized pain but does not address the underlying cause of hypercalcemia, which requires systemic management.
B. While rest may be beneficial for certain conditions, it does not directly address hypercalcemia. Encouraging mobility and adequate fluid intake is typically more effective.
C. Coughing and deep breathing exercises are important for preventing respiratory complications after surgery but are not relevant for managing hypercalcemia.
D. Increasing fluid intake promotes hydration and enhances urinary calcium excretion, helping to lower serum calcium levels and minimize complications associated with hypercalcemia
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