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. In the oliguric phase of acute kidney injury, fluid intake may need to be restricted rather than encouraged to prevent fluid overload.
B. Hourly intake and output monitoring is crucial for managing fluid balance and assessing the progression of kidney injury. Close monitoring can help prevent fluid overload, which is a risk due to the reduced urine output. It also aids in the timely adjustment of fluid administration and the detection of any changes in the client's condition that may necessitate intervention.
C. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are contraindicated in acute kidney injury as they can further impair renal function.
D. In the oliguric phase, protein intake may need to be restricted to reduce the workload on the kidneys and minimize azotemia. A high-protein diet can increase the burden on already compromised kidneys due to the increased production of urea, a byproduct of protein metabolism that requires excretion by the kidneys.
Correct Answer is ["A","B","C","F"]
Explanation
A. Increased premature ventricular contractions along with symptoms of anxiety and shortness of breath may indicate worsening cardiac function or an acute cardiac event, necessitating immediate medical attention.
B. Oxygen therapy may help alleviate symptoms of shortness of breath and improve oxygenation in patients experiencing cardiac symptoms.
C. These diagnostic tests can provide valuable information about cardiac function and any potential myocardial damage or ischemia, helping guide further treatment and management.
D. The modified Trendelenburg position may increase cardiac workload, which is not beneficial in the case of PVCs.
E. The patient should not be left alone due to the need for ongoing assessment and potential rapid intervention. Furthermore, leaving them alone could worsen their anxiety.
F. Elevating the head of the bed can aid in breathing and comfort, reducing the sensation of breathlessness.
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