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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A platelet count of 125,000/mm³ is lower than normal, and poses an increased risk of bleeding requiring immediate attention.
B. A hematocrit of 35% falls within the normal range for many individuals and does not indicate an urgent issue.
C. Weight loss may be a concern but is not typically considered a priority over other symptoms such as bone pain.
D. Bone pain in a client with leukemia is a common symptom of leukemia but does not require immediate attention compared to a low platelet count.
Correct Answer is C
Explanation
A. Lemon-glycerin swabs can dry out and irritate oral tissues, increasing the risk of oral mucositis and infection.
B. Using a firm toothbrush may be too harsh for irritated mucous membranes and can increase the risk of injury and bleeding.
C. Gentle oral care is essential to avoid further irritation of the mucous membranes.
D. Flossing may be too abrasive for irritated mucous membranes and can increase the risk of bleeding and injury.
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