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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Urinary output 25 mL/hr: This is below normal, but not an immediate airway threat.
B. Heart rate 122/min: Elevated HR is common in burns due to fluid shifts and stress.
C. Pain of 6 on a scale of 0 to 10: Pain is expected but not life-threatening.
D. Difficulty swallowing secretions: Indicates possible airway edema or inhalation injury, which can progress to airway obstruction. This is a medical emergency.
Correct Answer is ["C","D","E"]
Explanation
A. Calcium: Clients with CKD may have low calcium levels due to impaired vitamin D metabolism; calcium may need to be supplemented, not restricted.
B. Calories: Clients need sufficient calories to prevent catabolism. Calorie intake is typically maintained or increased, not restricted.
C. Phosphorus: Phosphorus builds up in CKD, leading to bone disorders and vascular calcification; must be limited.
D. Sodium: Sodium contributes to fluid retention and hypertension, which are problematic in CKD.
E. Protein: Protein intake is moderated (especially in non-dialysis clients) to reduce nitrogenous waste buildup, though dialysis clients may need more.
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