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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Correct Answer is D
Explanation
A. Facial flushing is not typically associated with end-stage kidney disease and waiting for transport to dialysis. It may be indicative of other conditions such as fever, allergic reactions, or hormonal changes.
B. Hypotension is not a common finding in patients with end-stage kidney disease.
These patients often experience hypertension due to fluid overload and electrolyte imbalances.
C. Diaphoresis, or excessive sweating, is not typically associated with end-stage kidney disease and waiting for transport to dialysis. It may occur in response to other factors such as fever, pain, or anxiety.
D. Peripheral edema, or swelling in the extremities, is a common finding in patients with end-stage kidney disease due to fluid retention and impaired fluid balance regulation.
Correct Answer is B
Explanation
A. Atrial fibrillation is characterized by rapid, irregular electrical impulses originating from the atria, resulting in a quivering or fibrillating motion of the atria rather than a coordinated contraction.
B. Asystole is the absence of any electrical activity on the cardiac monitor, resulting in a flat line. It indicates the absence of ventricular contraction and is considered a medical emergency requiring immediate intervention (CPR and advanced cardiac life support).
C. Ventricular fibrillation is characterized by chaotic, disorganized electrical activity in the ventricles, resulting in ineffective quivering of the ventricles and loss of cardiac output.
D. Atrial flutter is characterized by rapid but regular electrical impulses originating from the atria, resulting in a sawtooth pattern on the ECG tracing.
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