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. While bone involvement can occur in Hodgkin lymphoma, it is not typically associated with a high risk of spontaneous pathological fractures compared to multiple myeloma.
B. Multiple myeloma is characterized by the destruction of bone tissue, leading to an increased risk of spontaneous pathological fractures.
C. Leukemia primarily affects the bone marrow and may cause bone pain but does not typically lead to spontaneous pathological fractures.
D. Hemophilia is a bleeding disorder characterized by a deficiency in clotting factors and is not directly associated with an increased risk of spontaneous pathological fractures.
Correct Answer is A
Explanation
A. Using a systematic method for analyzing ECG tracings helps ensure that abnormalities are not overlooked, promoting accurate interpretation and diagnosis. This approach reduces the risk of diagnostic errors and ensures thorough assessment of cardiac rhythm and conduction abnormalities.
B. While using a systematic method may aid memory, its primary purpose is to ensure thoroughness and accuracy in ECG interpretation, rather than solely enhancing memory retention.
C. Indeed, using a systematic method establishes a routine for analyzing ECG tracings, aiding in consistent and comprehensive assessment, which is crucial for detecting subtle changes and abnormalities.
D. While using a systematic method may ultimately save time by preventing errors and ensuring efficiency, its primary purpose is accuracy rather than speed. The focus is on comprehensive analysis rather than expediency.
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