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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased appetite: Not typical in AKI; anorexia is more common.
B. Elevated serum creatinine levels: A hallmark of AKI, indicating reduced kidney filtration capacity.
C. Hyperglycemia: Not a direct indicator of AKI, though may occur in diabetics.
D. Increased urine output: AKI is typically oliguric (low urine output) or anuric in early phases.
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.
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