A nurse is assessing a client who has a medical history of chronic kidney disease for fluid volume excess. Which assessment data provides the most reliable measure of fluid retention?
Intake and output
Daily weight
Sodium level
Skin tenting
The Correct Answer is B
A. Intake and output: Although helpful, intake and output measurements can sometimes be inaccurate, as not all fluid retention may be recorded.
B. Daily weight: Daily weight measurements are the most reliable way to assess fluid retention because changes in body weight accurately reflect gains or losses in body fluid, especially in clients with chronic kidney disease.
C. Sodium level: Sodium levels can indicate fluid imbalances, but they do not directly measure fluid volume excess.
D. Skin tenting: Skin tenting is used to assess dehydration, not fluid retention, and is not a reliable measure in chronic kidney disease.
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Correct Answer is B
Explanation
A. Prepare an incident report for risk management: While this is necessary, it’s not the priority action as it doesn’t directly address the immediate need for type and cross-matching.
B. Inform the provider of the delay in obtaining the type and cross-match: The nurse should inform the provider first to allow for any changes to the client's preoperative plan. Immediate notification is essential for any follow-up actions, as blood products might be required, or surgery could be rescheduled if the match is not completed.
C. Obtain the client's type and cross-match: This action would be appropriate if it had not already been ordered. Since the order exists, the provider should be informed of the delay first to guide further steps.
D. Document the incident in the client's medical record: Documentation is important but should occur after informing the provider and obtaining the blood work, as it does not directly address the current client care needs.
Correct Answer is ["B","C","D","E"]
Explanation
A. Cleanses the ear molds with isopropyl alcohol to remove cerumen: Alcohol is not recommended for cleaning hearing aids, as it can damage the device. A mild soap and water solution or a designated cleaning tool is preferable.
B. Turns off the hearing aids when not in use: Turning off hearing aids conserves battery life, which is a proper maintenance practice.
C. Inspects the ear molds to determine the ear canal portion: Properly positioning the hearing aids ensures correct use and comfort.
D. Turns the volume all the way down before inserting the hearing aids: This prevents a sudden loud noise that could startle the client and allows them to adjust to a comfortable volume after insertion.
E. Ensures that the ears are not blocked with cerumen: Blocked cerumen can interfere with hearing aid functionality, so this is an essential step.