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?
Wheezing in all lung fields.
Pitting edema in bilateral lower extremities.
Oral fluid intake of 2000 mL in 24 hours.
Significant fatigue for more than one month.
The Correct Answer is B
A. Wheezing in all lung fields may indicate respiratory issues but does not directly support the diagnosis of Excess Fluid Volume.
B. Pitting edema in bilateral lower extremities is a classic sign of fluid overload, which directly supports the diagnosis of Excess Fluid Volume.
C. An oral fluid intake of 2000 mL in 24 hours is within normal limits for an adult and does not necessarily indicate Excess Fluid Volume without other symptoms.
D. Significant fatigue for more than one month could be related to a variety of conditions and is too nonspecific to support the diagnosis of Excess Fluid Volume without additional assessment data.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incompetence: Incompetence refers to a lack of skill or ability to perform a task effectively. It is not a desirable quality in a leader and would hinder rather than facilitate the implementation of new processes.
B. Integrity: Integrity is essential for a leader but is not specifically related to implementing new suggestions or initiatives. Integrity involves honesty, ethics, and adherence to moral principles.
C. Initiative: Initiative refers to the ability to take action and drive forward new ideas or projects. A leader with initiative is proactive and encourages innovation and improvement within the organization. Implementing suggestions for streamlining processes requires initiative to initiate change and drive improvement.
D. Fear: Fear is not a desirable quality in a leader when it comes to implementing changes or new initiatives. Leaders need to be confident, decisive, and willing to take calculated risks to drive positive change and improvement. Fear can inhibit innovation and progress.
Correct Answer is B
Explanation
A. Obtain pulse oximetry every two hours: While monitoring oxygen saturation is important in assessing respiratory status, it is not a direct intervention for preventing atelectasis. It is more of an assessment tool to evaluate the effectiveness of interventions aimed at preventing atelectasis.
B. Teach the client how to use the incentive spirometer: Incentive spirometry is a valuable tool for preventing atelectasis postoperatively by promoting deep breathing and lung expansion. Teaching the client how to use the incentive spirometer and encouraging its frequent use can help maintain lung volume and prevent collapse of alveoli.
C. Instruct the client to practice abdominal breathing: While abdominal breathing can be beneficial for promoting relaxation and reducing anxiety, it is not as effective as incentive spirometry in preventing atelectasis postoperatively.
D. Encourage oral fluid intake of 2000 mL/24 hours: Adequate hydration is important for overall health and respiratory function, but it is not specifically targeted at preventing atelectasis. While hydration can help maintain airway secretions thin, it is not the primary intervention for preventing atelectasis after a lobectomy.
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