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 D
Explanation
A. Flat: A flat abdomen is level with no visible protrusions or concavities.
B. Protuberant: A protuberant abdomen appears swollen or distended, common in obesity or ascites.
C. Rounded: A rounded abdomen has a convex contour, commonly seen in children or adults with mild weight gain.
D. Scaphoid: A scaphoid abdomen appears sunken or concave, often showing visible lower ribs, suggesting malnutrition or dehydration.
Correct Answer is A
Explanation
A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. A hard, rigid abdomen suggests peritonitis, a life-threatening complication requiring immediate assessment and intervention.
B. The client who does not have a palpable thrill or auscultated bruit: This indicates a possible vascular access issue, but it is not as immediately life-threatening as peritonitis.
C. The client who is reporting a 3.6 kg weight gain and refusing dialysis: This weight gain could signal fluid overload, but refusal of dialysis would require a different approach that may not need immediate intervention unless symptoms worsen.
D. The client with a hemoglobin of 9.0 mg/dL and hematocrit of 26%: This low hemoglobin and hematocrit level may require treatment, but it is not an immediate life-threatening issue like peritonitis.