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?

Oxygen saturation 93%

Distended neck veins

The client has gained 1 pound since yesterday.

Return of skin to previous position when the client's shin is palpated

Answer and Explanation

The Correct Answer is B

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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Correct Answer is D

Explanation

A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not escharotomy.

B. "This procedure involves placing the client into a Whirlpool tub and removing the dead tissue.": This describes hydrotherapy or wound debridement.

C. "Dead tissue will be non-surgically removed.": Describes enzymatic or mechanical debridement.

D. "Incisions will be made in the burnt tissues to improve circulation.": Escharotomy relieves pressure caused by tight, burned skin (eschar) to restore blood flow and prevent compartment syndrome.

A. "You have a genetic tendency for the development of anemia." B. "The increased metabolic waste products in your body depress the bone marrow and cause anemia." C. "There is a decreased production by the kidneys of the hormone erythropoietin, which is the cause of your anemia." D. "You are not eating enough iron-rich foods, which is causing anemia."

Correct Answer is C

Explanation

A. "You have a genetic tendency for the development of anemia.”: Anemia in CKD is primarily due to impaired erythropoietin production, not genetics.

B. "The increased metabolic waste products in your body depress the bone marrow and cause anemia.”: While uremic toxins may have some marrow-suppressive effects, the main cause is lack of erythropoietin.

C. "There is a decreased production by the kidneys of the hormone erythropoietin which is the cause of your anemia.”: In CKD, damaged kidneys produce less erythropoietin, leading to reduced RBC production and anemia.

D. "You are not eating enough iron-rich foods, which is causing anemia.”: Although iron deficiency can contribute, this is not the primary cause in CKD-related anemia.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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