A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
Sodium level.
Tissue turgor.
Daily weight.
Intake and output.
The Correct Answer is C
Choice A rationale:
Sodium level is a laboratory parameter that can be helpful in assessing fluid balance, but it does not directly measure fluid retention. Abnormal sodium levels may indicate fluid imbalances, but it is not the most reliable measure of fluid retention.
Choice B rationale:
Tissue turgor refers to the skin's elasticity, and it can be used to assess dehydration rather than fluid retention. Poor turgor may indicate dehydration, but it does not specifically measure fluid volume increase.
Choice C rationale:
Daily weight is a reliable measure of fluid retention. An increase in weight over a short period may indicate fluid accumulation in the body, while a decrease in weight could signify fluid loss. It is essential to monitor weight consistently under standardized conditions (e.g., same time, same clothing) for accurate assessment.
Choice D rationale:
Intake and output records provide information about fluid intake and output but may not always reflect fluid retention accurately. It is helpful for assessing fluid balance, but daily weight is a more direct and reliable measure of fluid retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Digoxin. Choice A rationale:
Potassium chloride (KCL) is a supplement used to treat or prevent low potassium levels. While it can have side effects, visual disturbances are not typically associated with KCL. Therefore, it is not the medication the nurse suspects to be causing the problem.
Choice B rationale:
Warfarin (Coumadin) is an anticoagulant used to prevent blood clot formation. Visual disturbances are not a known side effect of warfarin. Therefore, it is unlikely to be the cause of the patient's symptoms.
Choice C rationale:
Aspirin (ASA) is a pain reliever and antiplatelet medication, and while it can cause visual disturbances in some cases, it is not a common or significant side effect. Aspirin is also not specifically linked to atrial fibrillation.
Choice D rationale:
Digoxin (Lanoxin) is used to treat atrial fibrillation and heart failure. Visual disturbances are a known side effect of digoxin toxicity. Given the patient's diagnosis of atrial fibrillation and the reported symptoms, the nurse suspects the problem lies with digoxin and should further investigate and report to the provider.
Correct Answer is ["A","D"]
Explanation
The correct answer is A. Limit intake of canned soups and D. Read labels on foods before eating.
Choice A rationale:
Canned soups often contain high levels of sodium, which can contribute to exceeding the recommended daily sodium intake. Limiting these can help manage sodium levels effectively.
Choice B rationale:
Choosing diet sodas over bottled water is not advisable. Diet sodas can still contain sodium and other additives that are not beneficial for a low-sodium diet. Bottled water is a better choice as it typically contains no sodium.
Choice C rationale:
Bottled salad dressings often contain high amounts of sodium. Opting for homemade or low-sodium versions is a better strategy for maintaining a low-sodium diet.
Choice D rationale:
Reading labels on foods before eating is crucial for identifying hidden sources of sodium and making informed dietary choices. This practice helps in adhering to a low-sodium diet by avoiding foods with high sodium content.
: 3
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