A nurse is assessing a client who has a medical history of chronic kidney disease for fluid volume excess. Which assessment data provides the most reliable measure of fluid retention?

Intake and output

Daily weight

Sodium level

Skin tenting

Answer and Explanation

The Correct Answer is B

A. Intake and output: Although helpful, intake and output measurements can sometimes be inaccurate, as not all fluid retention may be recorded.

B. Daily weight: Daily weight measurements are the most reliable way to assess fluid retention because changes in body weight accurately reflect gains or losses in body fluid, especially in clients with chronic kidney disease.

C. Sodium level: Sodium levels can indicate fluid imbalances, but they do not directly measure fluid volume excess.

D. Skin tenting: Skin tenting is used to assess dehydration, not fluid retention, and is not a reliable measure in chronic kidney disease.

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Correct Answer is B

Explanation

A. Positive Skin Hypersensitivity Test: This is incorrect as it typically involves pain or discomfort with light touch, unrelated to rebound tenderness.

B. Positive Rovsing Sign: A positive Rovsing sign occurs when pain is felt in the right lower quadrant upon palpation of the left lower quadrant, indicating possible appendicitis.

C. Psoas Sign: This is elicited by extending the hip, and a positive sign indicates irritation of the iliopsoas muscle, often seen in appendicitis.

D. Positive Obturator Sign: This involves internal rotation of the hip, also used in appendicitis assessments but involves different positioning.

A. At the symphysis pubis. B. In the left lower quadrant. C. At the umbilicus. D. In the right lower quadrant.

Correct Answer is A

Explanation

A. At the symphysis pubis: When the bladder is distended, it typically extends upward from the symphysis pubis. Therefore, the nurse should start palpation here to assess for bladder distention.

B. In the left lower quadrant: This location would be used to assess for structures like the descending colon or potential masses, not the bladder.

C. At the umbilicus: The bladder does not typically reach the umbilical region unless it is severely distended, making this less effective as a starting point.

D. In the right lower quadrant: This area is primarily used to assess structures such as the appendix or ascending colon, not the bladder.

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A nurse is assessing a client who has a medical history of chronic kidney disease for fluid volume excess. Which assessment data provides the most reliable measure of fluid retention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

Correct Answer is B

Explanation

A client's bladder is found to be distended. At which location would the nurse begin palpating?

Correct Answer is A

Explanation

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