A nurse is planning care for a client with acute kidney injury.
The nurse should recognize that which assessment data best supports the nursing diagnosis of Excess Fluid Volume?

Axillary temp 102°F (38.9°C), client shivering – Declined
The client’s temperature has increased (from 38.2°C to 38.9°C) with shivering, indicating worsening fever possibly due to infection or disease progression. This suggests systemic deterioration.

· Client resting in recliner – Improved
The client remains seated calmly, suggesting improved comfort and reduced agitation compared to earlier reports of restlessness and sleeplessness.

· RR 12/min, regular – Improved
A drop from 18/min to a slower, regular respiratory rate can indicate reduced anxiety or pain, and better oxygenation or sedation effect.

· Client calm, not agitated – Improved
Previously reported as agitated and confused, the client is now calm, which indicates a response to pain management and supportive care.

· Grimaces with movement – No Change
Grimacing shows pain persists with movement, indicating that chronic or severe pain is still present despite medication.

· Respirations irregular with periods of apnea – Declined
This pattern suggests Cheyne-Stokes or end-of-life breathing changes, a significant clinical decline.

· Productive cough – No Change
The cough remains unchanged, indicating persistent airway secretions or pulmonary involvement.

· Oral mucous membranes dry – Declined
Dehydration or reduced intake continues or worsens, shown by dry mucosa, indicating physical decline.

· Coarse rhonchi bilaterally – Declined
Rhonchi worsening or spreading bilaterally suggests progression of respiratory congestion or infection.

· Crackles in bases – No Change
Basal crackles are still present, indicating fluid or infection in the lower lungs, with no improvement.

Choice A rationale

Medical errors are frequently the result of poorly coordinated care, often stemming from communication breakdowns, fragmented systems, and lack of clear protocols among healthcare providers and departments. Scientific evidence consistently links systemic failures in care coordination to an increased incidence of adverse events and medical errors. Optimizing coordination across the healthcare continuum is a key strategy for enhancing patient safety.

Choice B rationale

Medication errors are almost universally unintentional. They arise from various factors including miscalculations, transcription errors, improper administration techniques, or miscommunication. While negligence can play a role, the vast majority of medication errors are not deliberate acts. Healthcare systems focus on developing robust error prevention strategies to minimize the likelihood of these unintended events through process improvements and technology.

Choice C rationale

As many as 50% of adverse drug events (ADEs) are preventable. This high percentage underscores the importance of implementing evidence-based strategies, such as medication reconciliation, barcode medication administration, clinical decision support systems, and thorough patient education. Many ADEs result from predictable drug-drug interactions, incorrect dosages, or allergies that could be intercepted with proactive interventions and careful monitoring.

Choice D rationale

Hand-off errors are a significant cause of adverse events. Poor communication during transitions of care, such as shift changes or patient transfers, can lead to critical information being omitted, misunderstood, or miscommunicated. This can result in delayed diagnoses, inappropriate treatments, or medication errors, highlighting the need for standardized and effective hand-off protocols to ensure patient safety and continuity of care.