A nurse is caring for a client with acute renal failure who is at risk for impaired skin integrity. What intervention should the nurse implement to prevent skin breakdown?

A. Incorrect. Encouraging the client to sit up in a chair for extended periods can increase pressure on certain areas and contribute to skin breakdown.

B. Incorrect. Applying a heating pad to areas at risk for skin breakdown can lead to thermal injury and exacerbate skin issues.

C. Correct. Regular repositioning and skin assessments are essential in preventing pressure ulcers and maintaining skin integrity in clients with acute renal failure who may be bedridden or have limited mobility.

D. Incorrect. Adhesive tape can cause skin irritation and damage when removed, especially in clients at risk for impaired skin integrity.

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.