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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Complete Heart Block: Complete heart block (third-degree AV block) occurs when there is no communication between the atria and ventricles. The atria and ventricles beat independently, resulting in a very slow ventricular rate. This rhythm is characterized by regular P waves that have no relation to the QRS complexes.

B. Sinus Tachycardia: Sinus tachycardia is a rhythm originating from the sinoatrial node with a heart rate typically between 100-150 beats per minute. The rhythm is regular, and the P waves precede each QRS complex consistently.

C. Ventricular Tachycardia: Ventricular tachycardia is a fast heart rhythm that originates from the ventricles. It is characterized by wide and abnormal QRS complexes with a rate usually between 150-250 beats per minute. There may be no visible P waves, and if present, they are not associated with the QRS complexes.

D. Idioventricular Rhythm: Idioventricular rhythm is a slow rhythm originating from the ventricles with a heart rate usually between 20-40 beats per minute. It has wide and abnormal QRS complexes and no visible P waves.

A. Constipation B. Cough C. Tremor D. Bradycardia

Correct Answer is D

Explanation

A. Constipation: Constipation is not a common adverse effect of Atenolol, which is a beta- blocker.

B. Cough: Cough is more commonly associated with ACE inhibitors rather than beta-blockers like Atenolol.

C. Tremor: Tremor is not typically an adverse effect of Atenolol; beta-blockers can actually be used to treat essential tremors.

D. Bradycardia: Atenolol, as a beta-blocker, can slow the heart rate, leading to bradycardia, which is a well-documented adverse effect.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Identify the following Cardiac Rhythm:

Correct Answer is C

Explanation

A nurse is teaching a client diagnosed with hypertension and is prescribed Atenolol. Which of the following findings should the nurse include as adverse effects of Atenolol?

Correct Answer is D

Explanation

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