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.
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Related Questions
Correct Answer is D
Explanation
A. Incorrect. While fluid restriction may be necessary in certain cases of acute renal failure, it should be prescribed and monitored by the healthcare provider based on the client's specific needs.
B. Incorrect. A high-protein diet can put additional strain on the kidneys, and it is not recommended for clients with acute renal failure.
C. Incorrect. Over-the-counter diuretics may not be safe for clients with acute renal failure and can lead to further electrolyte imbalances.
D. Correct. The nurse's best response is to encourage the client to follow their healthcare provider's instructions and avoid medications that may harm the kidneys. Compliance with prescribed treatment plans and avoiding nephrotoxic medications are essential to support kidney function and prevent further damage.
Correct Answer is C
Explanation
A. Incorrect. Muscle weakness and fatigue are manifestations of hyperkalemia, but they are not the most critical indicators of severe hyperkalemia.
B. Incorrect. Tingling sensations in the extremities are not the most critical indicator of severe hyperkalemia.
C. Correct. The most critical manifestation of severe hyperkalemia is an irregular heart rhythm (dysrhythmiA. , which can be life-threatening.
D. Incorrect. Excessive thirst and dry mucous membranes are not specific to hyperkalemia and are not the most critical indicators of severe hyperkalemia.
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