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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Auscultate the antecubital fossa using a Doppler stethoscope: The graft is located in the forearm, not the antecubital fossa.

B. Measure the client's blood pressure to ensure it is higher in the left arm than the right: This does not assess AV graft patency and blood pressure should be avoided in the arm with a graft.

C. Auscultate the site for a bruit: The presence of a bruit and thrill indicates blood flow through the graft, confirming patency.

D. Check the brachial and radial pulses of the left arm simultaneously: While peripheral pulses can offer some insight, they do not directly confirm graft patency.

A. Oxygen saturation 93% B. Distended neck veins C. The client has gained 1 pound since yesterday. D. Return of skin to previous position when the client's shin is palpated

Correct Answer is B

Explanation

A. Oxygen saturation 93%:
While this is slightly below normal, it is not a definitive or specific indicator of fluid overload.

B. Distended neck veins:
Jugular vein distention is a classic sign of fluid overload and increased central venous pressure.

C. The client has gained 1 pound since yesterday:
A 1-pound weight gain could be due to fluid retention, but it's not significant enough on its own to confirm fluid overload.

D. Return of skin to previous position when the client's shin is palpated:
This indicates normal skin turgor and does not suggest fluid overload; instead, it rules out dehydration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

Correct Answer is C

Explanation

A nurse is assessing a client diagnosed with end-stage renal disease (ESRD) that is receiving hemodialysis. Which of the following findings should the nurse identify as an indication that the client is experiencing fluid overload?

Correct Answer is B

Explanation

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?

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