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 B
Explanation
Choice A rationale:
A phosphorus level of 4.5 mEq/L falls within the normal range, which is typically between 2.5 to 4.5 mEq/L. Although it's essential to monitor phosphorus levels, it is not the priority finding in this scenario.
Choice B rationale:
A potassium level of 2.9 mEq/L is the priority finding. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. A potassium level of 2.9 mEq/L indicates severe hypokalemia, which can lead to life-threatening cardiac arrhythmias and muscle weakness. Immediate intervention is necessary to address the potassium imbalance.
Choice C rationale:
A calcium level of 8.2 mg/dL falls within the normal range (typically 8.5 to 10.2 mg/dL). While calcium levels are essential to monitor, they do not take precedence over the critically low potassium level in this situation.
Choice D rationale:
A sodium level of 145 mEq/L falls within the normal range, which is usually around 135 to 145 mEq/L. Although monitoring sodium levels is important, it is not the priority finding when compared to the critically low potassium level.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
Dysrhythmias are not a direct consequence of diabetic ketoacidosis (DKA) or the acid-base imbalance indicated by the patient's pH of 7.2 and bicarbonate level of 20 mEq/L. DKA primarily affects the respiratory system, leading to Kussmaul respirations, not dysrhythmias.
Choice B rationale:
Kussmaul respirations are an expected finding in a patient with diabetic ketoacidosis (DKA) and metabolic acidosis. These deep, rapid breaths are the body's attempt to compensate for the acidosis by eliminating excess CO2.
Choice C rationale:
Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.
Choice D rationale:
Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.
Choice E rationale:
Tachycardia is an expected finding in a patient with DKA. The metabolic acidosis and dehydration lead to an increase in heart rate as the body attempts to maintain perfusion.
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