A nurse is assessing a client with acute renal failure for signs of fluid overload. Which clinical manifestation is associated with fluid overload in this client?
Hypotension and tachycardia.
Dry mucous membranes and decreased skin turgor.
Crackles in the lungs and edema in the extremities.
Hypoactive bowel sounds and constipation.
The Correct Answer is C
A. Incorrect. Hypotension and tachycardia are more commonly associated with fluid depletion, not fluid overload.
B. Incorrect. Dry mucous membranes and decreased skin turgor are signs of dehydration, which is not indicative of fluid overload.
C. Correct. Fluid overload in acute renal failure can lead to pulmonary congestion and edema in the extremities. Crackles in the lungs (rales) are auscultated when there is fluid accumulation in the lung tissue, and edema in the extremities is visible swelling caused by excessive fluid retention.
D. Incorrect. Hypoactive bowel sounds and constipation are not directly related to fluid overload in acute renal failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Hemodialysis is not a procedure for kidney transplantation.
B. Correct. Hemodialysis is a treatment that helps remove waste products, toxins, and excess fluids from the blood when the kidneys are not functioning properly. It helps maintain the body's internal environment and prevent complications of acute renal failure.
C. Incorrect. While hemodialysis can improve kidney function temporarily, its primary purpose is to provide kidney support and replace some of the kidney's functions.
D. Incorrect. The description provided refers to the insertion of a urinary catheter for bladder drainage, not hemodialysis.
Correct Answer is A
Explanation
A. Correct. Loop diuretics can cause potassium loss and potentially lead to hypokalemia. The nurse should monitor the client's serum potassium levels frequently to assess for any imbalances.
B. Incorrect. While loop diuretics can be given intravenously for rapid action, the administration route depends on the client's condition and the healthcare provider's order.
C. Incorrect. Loop diuretics are used to promote diuresis and fluid removal from the body. Encouraging fluid restriction while on diuretic therapy may exacerbate dehydration and electrolyte imbalances.
D. Incorrect. The timing of loop diuretic administration is determined by the healthcare provider's order and the client's specific needs. Taking diuretics at bedtime may result in increased nighttime urination and sleep disruption.
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