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. Showering is not typically restricted after a splenectomy. Good hygiene practices, including regular showering, are important for preventing infection.
B. Patients who have undergone a splenectomy are at increased risk of infections, particularly from encapsulated bacteria such as Streptococcus pneumoniae. Yearly flu vaccination helps reduce the risk of influenza-related complications.
C. Long-term antibiotic prophylaxis is not routinely recommended for all patients after splenectomy. Antibiotics may be prescribed in certain situations, such as for postsplenectomy sepsis prevention, but lifelong use is not standard practice.
D. Sleeping position is not directly related to infection prevention after splenectomy.
General infection prevention measures, such as vaccination and avoiding exposure to sick individuals, are more important.
Correct Answer is ["A","C","D","E"]
Explanation
A. The primary function of the kidneys is to filter blood and eliminate waste products as urine.
B. Vitamin B12 activation primarily occurs in the liver, not the kidneys.
C. The kidneys help regulate the body's acid-base balance by excreting or conserving bicarbonate ions and hydrogen ions.
D. The kidneys produce erythropoietin, a hormone that stimulates the production of red blood cells in the bone marrow.
E. The kidneys play a key role in regulating blood pressure by adjusting the volume of blood and the balance of electrolytes in the body. They also produce hormones such as renin, which helps regulate blood pressure.
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