The nursing diagnosis of Excess Fluid Volume is made for a patient with chronic kidney disease. Which of the following data is most important for the nurse to collect for this patient based on the nursing diagnosis?
daily weight
vital signs
intake and output
skin turgor
The Correct Answer is C
A. Daily weight monitoring is important for assessing fluid status but may not provide real-time information about fluid balance changes.
B. Vital signs are important for overall assessment but may not specifically address the nursing diagnosis of Excess Fluid Volume unless there are significant changes indicative of fluid overload or dehydration.
C. Monitoring intake and output provides direct information about fluid balance and renal function, helping to identify trends and assess the effectiveness of interventions aimed at managing fluid volume.
D. Skin turgor assessment is useful for evaluating hydration status but may not provide comprehensive data on fluid volume excess alone.
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Related Questions
Correct Answer is C
Explanation
A. Adequate hydration is essential for preventing UTIs as it helps flush bacteria from the urinary tract.
B. Voiding after sexual intercourse can help flush out bacteria that may have entered the urinary tract during intercourse, reducing the risk of UTIs.
C. Wiping from back to front after urination can introduce bacteria from the anal area to the urethra, increasing the risk of UTIs. The correct technique is to wipe from front to back.
D. Bubble baths can introduce irritants and bacteria into the vaginal and perineal area, increasing the risk of UTIs. Avoiding bubble baths is a recommended prevention measure.
Correct Answer is B
Explanation
A. A negative waveform indicates a downward deflection from the baseline on an ECG tracing, which may correspond to electrical activity such as depolarization or repolarization of cardiac chambers.
B. An isoelectric line represents the baseline on an ECG tracing when there is no net electrical activity occurring in the heart. It appears flat and represents a period of electrical silence.
C. A downward deflection on an ECG tracing refers to a negative waveform, as mentioned above.
D. A positive waveform on an ECG tracing indicates an upward deflection from the baseline, representing electrical activity such as depolarization or repolarization.
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