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 C
Explanation
A. Appendix: Located in the right lower quadrant, the appendix is unlikely to be impacted in left upper quadrant trauma.
B. Left ureter: The left ureter is located lower in the abdomen along the flank area and is not directly impacted in the left upper quadrant.
C. Left lobe of liver: The liver’s left lobe extends into the left upper quadrant, making it a likely organ to be impacted in blunt trauma to this area, particularly given its large size and location near the abdominal wall.
D. Sigmoid colon: Positioned lower in the left lower quadrant, the sigmoid colon is less likely to be affected by left upper abdominal trauma.
Correct Answer is ["A","E","F"]
Explanation
A. Ensure comfortable seating at eye level for the client and nurse: Establishes a non-intimidating environment, helping the client feel more at ease.
B. Provide seating for the client so that the client faces a strong light: Incorrect; this may cause discomfort and make the client feel scrutinized.
C. Ensure that the distance between the client and nurse is at least 7 ft: Too great a distance for effective communication; ideal distance is 3-4 feet.
D. Place a chair for the client across from the nurse's desk: Creates a formal, potentially intimidating setting, discouraging openness.
E. Set the room temperature at a comfortable level: Ensures physical comfort, aiding in client relaxation and openness.
F. Remove distracting objects from the interviewing area: Minimizes potential distractions, keeping the client focused and the environment conducive to communication.