The nurse is planning care for the client with acute renal failure. The nurse plans the client's care based on the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis?
A) Pitting edema in the lower extremities
B) Bowel sounds positive in 4 quadrants
C) Wheezing in the lungs
D) Generalized weakness
Answer: A
The client in acute renal failure will likely be edematous, as the kidneys are not producing urine. Wheezing in the lungs is an assessment consistent with asthma. Bowel sounds in 4 quadrants is a normal assessment finding. Generalized weakness may be due to whatever disease process precipitated the renal failure.
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