A nurse is reinforcing teaching about monitoring weight with a client who has chronic kidney disease. Which of the following instructions should the nurse include in the teaching?

Use several different scales to obtain the weight.

Weigh at the same time each day.

Calibrate weight scales every week.

Measure weight just prior to voiding.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Using several different scales to obtain the weight is incorrect. Consistency is key when monitoring weight, especially for clients with chronic kidney disease. Using the same scale ensures that weight measurements are accurate and comparable over time. Different scales may have slight variations, leading to inconsistent and unreliable data.
Choice B rationale
Weighing at the same time each day is correct. It is important to weigh at the same time each day, preferably in the morning after voiding and before eating, to obtain consistent and accurate measurements. This helps in monitoring fluid retention and changes in body weight, which are critical for managing chronic kidney disease.
Choice C rationale
Calibrating weight scales every week is not necessary. While it is important to ensure that the scale is accurate, weekly calibration is excessive. Regular calibration according to the manufacturer’s instructions or as needed is sufficient to maintain accuracy. Over-calibration can be time-consuming and may not significantly improve measurement accuracy.
Choice D rationale
Measuring weight just prior to voiding is incorrect. Weighing after voiding provides a more accurate measurement of body weight without the influence of bladder contents. This is especially important for clients with chronic kidney disease, as fluid balance and retention are closely monitored.

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Correct Answer is A

Explanation

Choice A rationale
Serving cooked fruit with meals is an appropriate intervention for a client with a low WBC count after chemotherapy. Cooking fruit helps eliminate potential pathogens, reducing the risk of infection.
Choice B rationale
Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is not appropriate. A lower threshold for fever should be used, as even a slight increase in temperature can indicate infection in immunocompromised clients.
Choice C rationale
Placing the client in a room with negative-pressure airflow is not necessary for clients with low WBC counts. This intervention is typically used for clients with airborne infections.
Choice D rationale
Instructing the client to use an incentive spirometer every 4 hours is beneficial for lung health but does not directly address the risk of infection associated with low WBC counts.

A. Frothy sputum. B. Orthopnea. C. Dyspnea. D. Peripheral edema.

Correct Answer is D

Explanation

Choice A rationale
Frothy sputum is more commonly associated with left-sided heart failure, where fluid backs up into the lungs. It is not a typical finding in right-sided heart failure.
Choice B rationale

Orthopnea, or difficulty breathing while lying flat, is more commonly associated with left-sided heart failure. Right-sided heart failure primarily affects the systemic circulation.
Choice C rationale
Dyspnea, or shortness of breath, can occur in both left-sided and right-sided heart failure. However, it is more prominently associated with left-sided heart failure.
Choice D rationale
Peripheral edema, or swelling in the legs and ankles, is a common finding in right-sided heart failure. It occurs due to the backup of blood in the systemic circulation, leading to fluid accumulation in the tissues.

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A nurse is reinforcing teaching about monitoring weight with a client who has chronic kidney disease. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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