Level: Clinical
Difficulty: Medium
Subtopic: Parenteral nutrition
NCLEX: A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to parenteral nutrit…
Nutrition Basic Care and Comfort
Case Study
A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to parenteral nutrition. Assessment data include the client has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.