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. 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.
Correct Answer is A
Explanation
A. "You must feel frustrated." This response is therapeutic and validates the nurse’s feelings, encouraging the nurse to open up about their frustration without feeling judged or defensive.
B. "Why do you feel upset about this?": Asking “why” may make the nurse defensive and feel as though they need to justify their feelings.
C. "You should be working harder.": This is unsupportive and could worsen the nurse’s frustration, possibly making them feel criticized or undervalued.
D. "I will reprimand your team members.": This response is reactive and could disrupt team dynamics without addressing the underlying issue. It does not support open communication.