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. Chemotherapy is only used for palliation: While chemotherapy can be used for palliative care to relieve symptoms and improve quality of life in advanced cancer, it is also used with curative intent in some cases, especially when cancer is diagnosed early or is responsive to chemotherapy.

B. Chemotherapy cures prostate cancer that has metastasized to the bone: Chemotherapy alone is generally not curative for prostate cancer that has metastasized to the bone. It may help slow disease progression, relieve symptoms, or prolong survival, but it is not typically curative on its own.

C. Chemotherapy is used in conjunction with other treatment modalities in this type of cancer: Chemotherapy is often used in combination with other treatment modalities such as hormone therapy, radiation therapy, or surgery in the management of prostate cancer with bone metastasis. The goal is to target cancer cells using multiple approaches to achieve the best possible outcome for the patient.

D. Chemotherapy makes the body fluid a biohazard: Chemotherapy drugs can be excreted in body fluids such as urine, saliva, and sweat, making them potentially hazardous. However, this statement does not specifically address the role of chemotherapy in the treatment of prostate cancer with bone metastasis.

A. Client has increased urine specific gravity. B. Changes in the client's behavior. C. Client is complaining of nausea. D. Client is complaining of severe headache. E. Client's urine output is only 50 cc/hr.

Correct Answer is ["A","B","C","D"]

Explanation

A. Client has increased urine specific gravity: Increased urine specific gravity indicates concentrated urine, which is a hallmark of SIADH and should be reported as it reflects the excessive retention of water.

B. Changes in the client's behavior: Behavioral changes can be indicative of hyponatremia, a serious complication of SIADH, and should be reported immediately.

C. Client is complaining of nausea: Nausea is a symptom of hyponatremia, which is a common and dangerous consequence of SIADH that needs prompt attention.

D. Client is complaining of severe headache: A severe headache can also be a sign of hyponatremia and potential cerebral edema, both of which are critical conditions needing urgent intervention.

E. Client's urine output is only 50 cc/hr: While reduced urine output can be associated with SIADH, 50 cc/hr is not extremely low and might not be immediately alarming on its own. The other symptoms are more critical and should take precedence in reporting to the provider.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for chemotherapy due to bone metastasis of prostate cancer. Which of the following statements about chemotherapy made by the nurse is correct?

Correct Answer is C

Explanation

A nurse is caring for a client who is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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