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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Incorrect. Hypertension is a risk factor for prerenal acute renal failure, not postrenal.

B. Incorrect. While a UTI can cause kidney injury, it is not directly related to postrenal acute renal failure.

C. Correct. An enlarged prostate, also known as benign prostatic hyperplasia (BPH), can cause obstruction of the urinary tract and lead to postrenal acute renal failure. The obstruction prevents urine flow, causing pressure buildup in the kidneys and impairing kidney function.

D. Incorrect. Chronic kidney disease (CKD. is a risk factor for intrinsic acute renal failure, not postrenal.

A. Monitor the client's serum potassium levels frequently. B. Administer the diuretics intravenously to ensure rapid action. C. Encourage the client to restrict fluid intake while on diuretic therapy. D. Instruct the client to take the diuretics at bedtime for better effectiveness.

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.

QUESTIONS

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client at risk for postrenal acute renal failure. What condition should the nurse prioritize in the client's assessment?

Correct Answer is C

Explanation

A client with acute renal failure is prescribed loop diuretics to manage fluid overload. What is the nurse's responsibility when administering loop diuretics?

Correct Answer is A

Explanation

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