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 A
Explanation
A. Check an apical pulse: Digoxin is known to cause toxicity, which can manifest as nausea, weakness, and anorexia. Bradycardia is a common sign of digoxin toxicity. Therefore, the nurse's first action should be to assess the client's apical pulse rate to determine if there are any signs of bradycardia, which could indicate digoxin toxicity.
B. Request a dietitian consult: While nutrition is important, the client's symptoms of nausea and weakness need immediate attention to rule out digoxin toxicity before considering dietary interventions.
C. Request an order for an antiemetic: Administering an antiemetic may be indicated if the client is experiencing nausea, but it's crucial to assess for digoxin toxicity first, as antiemetics may mask symptoms of toxicity.
D. Suggest that the client rests before eating the meal: Rest may be beneficial for the client, but addressing the potential cause of the symptoms, such as digoxin toxicity, takes priority
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