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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View Related questions
Correct Answer is A
Explanation
A. "When did your pain symptoms begin?" When conducting a focused assessment on pain, the nurse should gather specific details about the onset, location, duration, characteristics, and aggravating/relieving factors. Asking when the pain symptoms began helps clarify the onset, which is critical in assessing the pain's cause and severity.
B. "Do you think you know what caused the swelling?": This is less focused on pain and more on swelling, which may not be the client's main concern.
C. "What brings you to the clinic today?": While this is a good general question, it is not focused on pain and would not gather specific pain-related information.
D. "Can you go over what you said about nothing relieving the pain?": This question is not as open-ended or specific to a focused pain assessment as asking about onset.
Correct Answer is C
Explanation
A. Percussion, inspection, palpation, auscultation: This sequence could disturb bowel sounds by percussing before auscultation, making it difficult to assess them accurately.
B. Inspection, palpation, percussion, auscultation: Palpating before auscultating can alter bowel sounds, so it’s not the correct order.
C. Inspection, auscultation, percussion, palpation: This sequence is recommended for abdominal assessment to avoid altering bowel sounds. Inspection is done first to observe any visible abnormalities, followed by auscultation to listen to bowel sounds before palpating or percussing, which could disrupt the sounds.
D. Auscultation, inspection, palpation, percussion: Inspection should always be first, making this option incorrect as it begins with auscultation.