A client is receiving continuous ambulatory peritoneal dialysis (CAPD. and the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has serum albumin level at 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement?

Reference Range
Serum Albumin [Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)]

Recommend the use of support stockings to enhance venous return.

Ensure the client receives frequent small meals containing complete proteins.

Evaluate patency of the AV graft for resumption of hemodialysis.

Instruct the client to continue to follow the prescribed rigid fluid restriction amounts.

Answer and Explanation

The Correct Answer is B

Choice A: Recommending the use of support stockings to enhance venous return is not a priority intervention for the nurse, as this does not address the underlying cause of the peripheral edema, which is fluid overload due to inadequate dialysis. This is a distractor choice.

Choice B: Ensuring the client receives frequent small meals containing complete proteins is a priority intervention for the nurse, as this can help improve the client's nutritional status and increase their serum albumin level, which can reduce fluid leakage into the interstitial spaces and decrease edema. Therefore, this is the correct choice.

Choice C: Evaluating patency of the AV graft for resumption of hemodialysis is not a priority intervention for the nurse, as this is not feasible at this point since the AV graft is no longer available to use. This is another distractor choice.

Choice D: Instructing the client to continue to follow the prescribed rigid fluid restriction amounts is not a priority intervention for the nurse, as this does not address the root problem of inadequate dialysis and low serum albumin level, which are contributing to fluid overload and edema. This is another distractor choice.

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Free Nursing Study Resources

Correct Answer is ["4"]

Explanation

Step 1 is to convert the child’s weight from pounds to kilograms.

44 pounds ÷ 2.2 = 20 kilograms.

Result at each step = 20 kilograms.

Step 2 is to calculate the total dosage of furosemide in milligrams.

2 mg × 20 kg = 40 mg.

Result at each step = 40 mg.

Step 3 is to determine the volume of medication to administer in milliliters.

40 mg ÷ 10 mg/mL = 4 mL.

Result at each step = 4 mL.

The nurse should administer 4 mL.

A. Keep the bed in the lowest position and initiate seizure and fall precautions. B. Place an indwelling urinary catheter and measure strict intake and output. C. Maintain elevated positioning of the dependent joints on affected side. D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Correct Answer is D

Explanation

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

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Naxlex Comprehensive Predictor Exams

A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg intravenously every 12 hours. The medication is available at 10 mg/mL. How many mL should the nurse administer? (Enter numeric value only)

Correct Answer is ["4"]

Explanation

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Correct Answer is D

Explanation

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