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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hyperparathyroidism causes hypercalcemia, not hypocalcemia, by increasing calcium levels. Malnutrition in alcoholism depletes calcium, making this incorrect, as it’s the opposite condition compared to the nurse’s recognition of hypocalcemia risk in the client.
Choice B reason: NSAIDs don’t significantly affect calcium levels, unlike malnutrition, which depletes calcium stores. Alcoholism increases hypocalcemia risk, making this incorrect, as it’s not a primary risk factor compared to the nurse’s evaluation of the malnourished client.
Choice C reason: Tetracycline may bind calcium but is less likely to cause hypocalcemia than chronic malnutrition. Alcoholism is a stronger risk, making this incorrect, as it’s a minor factor compared to the nurse’s recognition of hypocalcemia risk in the elderly client.
Choice D reason: A 70-year-old with alcoholism and malnutrition has the greatest hypocalcemia risk due to poor dietary calcium and vitamin D absorption. This aligns with nutritional risk factors, making it the correct client the nurse would recognize as most at risk for hypocalcemia.
Correct Answer is D
Explanation
Choice A reason: Analyzing care levels is important, but the nurse’s negligence lies in not addressing the critical magnesium level. Reporting to the practitioner is the appropriate action, making this incorrect, as it’s less specific than the failure to act on a critical lab result.
Choice B reason: Respecting patient wishes relates to DNR but doesn’t negate the need to report critical labs for non-resuscitative care. Failure to act is the issue, making this incorrect, as it misapplies the DNR to the nurse’s duty to address the magnesium level.
Choice C reason: Wrongful death assumes patient harm or death, which isn’t indicated here. Failure to act on the critical magnesium level is the negligence, making this incorrect, as it overstates the outcome compared to the nurse’s inaction on the lab result.
Choice D reason: Failure to take appropriate action, such as reporting a critical magnesium level of 1.1 mEq/L, is negligent, regardless of DNR status. This aligns with nursing standards, making it the correct action the nurse neglected, as critical labs require practitioner notification.
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