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
Explanation
A. While a splenectomy can lead to increased workload on the liver, it does not directly predispose the patient to liver disease.
B. A history of splenectomy does not specifically increase the risk of lupus.
C. Patients who have undergone splenectomy are at increased risk of certain infections, particularly encapsulated bacteria such as Streptococcus pneumoniae, which can cause pneumonia.
D. A history of splenectomy does not directly increase the risk of renal disease.
Correct Answer is D
Explanation
A. While vitamin K plays a role in immune function, its administration prior to surgery primarily aims to correct potential clotting abnormalities rather than prevent infection.
B. Vitamin K does not affect gastric secretions. Its role in this context is unrelated to gastric function.
C. While vitamin K is involved in various physiological processes, its administration prior to surgery is primarily aimed at preventing bleeding complications by ensuring adequate clotting factor synthesis.
D. Vitamin K is essential for the synthesis of clotting factors in the liver.
Administering vitamin K prior to surgery helps ensure adequate levels of clotting factors, reducing the risk of bleeding during and after the procedure.
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