A nurse is assessing a client with chronic renal failure for potential fluid overload. Which finding should the nurse prioritize as an early clinical manifestation of fluid retention?
Increased blood pressure readings
Hyperkalemia (elevated potassium levels)
Dry and cracked skin
Polyuria (increased urination)
The Correct Answer is A
A. Correct. Increased blood pressure readings can be an early clinical manifestation of fluid overload in clients with chronic renal failure. Fluid retention can lead to hypertension as the kidneys struggle to excrete excess fluids.
B. Incorrect. Hyperkalemia may occur in chronic renal failure, but it is not an early clinical manifestation of fluid overload.
C. Incorrect. Dry and cracked skin is more commonly associated with dehydration rather than fluid overload.
D. Incorrect. Polyuria is not typically associated with fluid overload. Instead, it may be present in early stages of chronic renal failure due to the inability of the kidneys to concentrate urine properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Phosphate binders are most effective when taken with meals because they bind to dietary phosphorus, preventing its absorption in the digestive tract.
B. Incorrect. While constipation can be a side effect of some phosphate binders, drinking plenty of fluids is not directly related to this issue.
C. Incorrect. Phosphate binders should be taken with meals, and calcium supplements should be taken separately to prevent interactions between the two medications.
D. Incorrect. Phosphate binders do not typically lower potassium levels, and monitoring potassium intake is not specifically related to their use.
Correct Answer is B
Explanation
A. Incorrect. While assessing vital signs and blood pressure is important, it is not the first action when the client reports cloudy dialysate effluent during an exchange.
B. Correct. Cloudy dialysate effluent may indicate peritonitis, an infection of the peritoneal cavity. Obtaining a sample of the effluent for testing is the first action to determine if an infection is present and requires immediate treatment.
C. Incorrect. Instructing the client to stop the exchange immediately may be necessary if there are signs of infection or other complications, but obtaining a sample of the effluent should be done first to determine the cause.
D. Incorrect. Providing the client with an analgesic is not the priority when the client reports cloudy dialysate effluent; the focus is on identifying the cause of the cloudiness.
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