When planning care for the client with acute renal failure, the nurse selects ineffective breathing pattern as a nursing diagnosis. Which of the following assessment data by the nurse validate the nursing diagnosis selected?
1. Generalized edema
2. Wheezing in the lungs
3. Bowel sounds positive in 3 quadrants
4. Generalized weakness
1. Generalized edema
Rationale:
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 3 quarters are not related to kidney failure. Generalized weakness may be due to whatever disease process precipitated the renal failure.
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