A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 101.2°F (38.5°C). Which nursing action is most appropriate?

Encourage fluid intake.

Continue to monitor vital signs.

Notify the primary health care provider.

Monitor the site of the shunt for infection.

Answer and Explanation

The Correct Answer is C

Choice A reason: Encouraging fluid intake is inappropriate post-hemodialysis, as fluid overload is a risk. A fever of 101.2°F requires provider notification, making this incorrect, as it’s unsafe compared to the nurse’s priority of addressing a potential infection promptly.

Choice B reason: Monitoring vital signs is useful but doesn’t address the urgency of a 101.2°F fever post-hemodialysis, which may indicate infection. Notifying the provider is critical, making this incorrect, as it delays the nurse’s action to manage a serious complication.

Choice C reason: Notifying the provider is most appropriate for a fever of 101.2°F post-hemodialysis, as it may signal infection, a serious complication. This aligns with post-dialysis care priorities, making it the correct action for the nurse to take immediately.

Choice D reason: Monitoring the shunt site is relevant but less urgent than notifying the provider about a fever, which may indicate systemic infection. This is incorrect, as it delays the nurse’s priority of addressing the client’s elevated temperature post-hemodialysis.

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Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Administering oxygen improves oxygenation in air embolism, addressing hypoxia from chest pain and shortness of breath. This aligns with emergency dialysis protocols, making it a correct priority action the nurse would take to stabilize the client’s condition.

Choice B reason: Continuing dialysis, even slowly, risks worsening air embolism by introducing more air. Stopping dialysis is critical, making this incorrect, as it’s unsafe compared to the nurse’s priority of halting the procedure to prevent further embolism complications.

Choice C reason: Notifying the provider and Rapid Response Team ensures rapid intervention for air embolism, a life-threatening dialysis complication. This aligns with emergency protocols, making it a correct priority action the nurse would take to manage the client’s acute condition.

Choice D reason: Stopping dialysis and positioning the client on the left side with head down traps air in the right atrium, preventing pulmonary embolism. This is a standard intervention, making it a correct priority action for the nurse to address air embolism.

Choice E reason: Bolusing 500 mL saline doesn’t break up air emboli and risks fluid overload in kidney disease. Oxygen administration is appropriate, making this incorrect, as it’s ineffective compared to the nurse’s priority actions for managing air embolism.

A. Stoma is beefy red and shiny. B. Purple discoloration of the stoma. C. Skin excoriation around the stoma. D. Semiformed stool noted in the ostomy pouch.

Correct Answer is B

Explanation

Choice A reason: A beefy red, shiny stoma is normal, indicating healthy tissue perfusion. Purple discoloration suggests ischemia, making this incorrect, as it doesn’t require immediate notification compared to the nurse’s priority of reporting a potentially life-threatening stoma complication to the provider.

Choice B reason: Purple discoloration of the stoma indicates potential ischemia or necrosis, a serious complication requiring immediate provider notification. This aligns with colostomy care priorities, making it the correct observation for the nurse to report promptly to prevent further tissue damage or obstruction.

Choice C reason: Skin excoriation around the stoma is concerning but less urgent than purple discoloration, which signals ischemia. This is incorrect, as it can be managed with barrier creams, unlike the nurse’s priority of addressing a critical stoma issue requiring immediate intervention.

Choice D reason: Semiformed stool in the ostomy pouch is expected post-colostomy and not alarming. Purple discoloration is critical, making this incorrect, as it’s a normal finding compared to the nurse’s need to notify the provider about a potentially ischemic stoma.

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A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 101.2°F (38.5°C). Which nursing action is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

The nurse is providing care for a client with a bowel obstruction who had a transverse colostomy created. Which observation requires immediate notification of the primary health care provider?

Correct Answer is B

Explanation

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