A nurse is assessing a client diagnosed with chronic renal disease for fluid volume excess. The nurse should recognize that which of the following provides a reliable measure of fluid retention?
Sodium level
Tissue edema
Urinary output
Daily weight
The Correct Answer is D
A. Sodium level: Serum sodium levels can vary and are not a direct measure of fluid retention.
B. Tissue edema: Edema is subjective and can be influenced by other conditions.
C. Urinary output: Many CKD patients have limited or no urine output despite fluid retention.
D. Daily weight: Daily weights are the most reliable non-invasive measure for fluid status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bleeding may occur at injection sites when the intramuscular route is used: While possible, this is not the primary concern.
B. The client can experience nausea and vomiting when given oral medications: This may be true but is secondary to absorption issues.
C. Pain resulting from a burn injury requires relief by the fastest route available: Although IV is fast, the key issue is absorption.
D. Damaged tissue and edema may interfere with drug absorption via other routes: Burned and edematous tissue reduces IM and subcutaneous absorption, making IV the preferred route.
Correct Answer is C
Explanation
A. A combination of benzodiazepines and topical anesthetics: This is not effective for the deep and constant pain experienced with burns.
B. The use of oral opioids: Absorption may be delayed or unpredictable in critically ill burn clients.
C. A patient-controlled analgesia (PCA) system: PCA provides rapid and individualized control of pain, which is essential in the acute phase.
D. Distraction and relaxation techniques: These are supportive, not primary, strategies for severe pain.
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