A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?

The client has had a 3 lb weight gain since yesterday.

Flattened neck veins

Oxygen saturation 93%

Return of skin to previous position when the client's shin is palpated

Answer and Explanation

The Correct Answer is A

A 3 lb weight gain in a short period, especially overnight, is indicative of fluid overload in a client with end-stage kidney disease receiving hemodialysis. Hemodialysis is performed to remove excess fluid and waste products from the body. If the client is experiencing fluid overload, it means that their body is retaining more fluid than it should, and this can lead to complications such as pulmonary edema, heart failure, and other cardiovascular problems. The nurse should identify this finding as an indication of potential fluid overload and report it to the healthcare provider for further evaluation and intervention.

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Correct Answer is D

Explanation

ST-segment elevation on an electrocardiogram (ECG) is a critical finding and should be reported rapidly to the health care provider. It is a hallmark ECG change seen in myocardial infarction (heart attack). When there is myocardial ischemia or injury (such as in a heart attack), the ST segment

elevates above the baseline in the affected leads of the ECG. This elevation indicates that there is an ongoing loss of oxygen and blood supply to a part of the heart muscle.

ST-segment elevation is a medical emergency because it suggests acute coronary syndrome (ACS), which can rapidly progress to a myocardial infarction if not promptly treated. Immediate intervention is needed to restore blood flow to the affected coronary artery and prevent further damage to the heart muscle.

The other options listed (A) First-degree atrioventricular block, (B) Inverted P wave, and (C) Sinus tachycardia, while significant in some situations, do not have the same urgency as ST-segment elevation in the context of chest pain. They may require medical attention, but they do not typically indicate an acute myocardial infarction or an immediate life-threatening condition. ST-segment elevation is a critical finding that requires rapid intervention to preserve heart muscle function and prevent complications.

A. Increase in the patient's heart rate. B. Decrease in premature ventricular contractions. C. Increase in strength of peripheral pulses. D. Decrease in premature atrial contractions

Correct Answer is A

Explanation

Atropine is an anticholinergic medication that acts by blocking the effects of the parasympathetic nervous system on the heart, leading to an increase in heart rate (positive chronotropic effect) and conduction velocity (positive dromotropic effect). In patients with symptomatic type 1 second degree atrioventricular (AV) block (also known as Mobitz type 1 or Wenckebach), the electrical impulses between the atria and ventricles are delayed or blocked intermittently, resulting in a progressive lengthening of the PR interval until a ventricular beat is dropped.

When atropine is administered to a patient with symptomatic type 1 AV block, it can counteract the increased vagal tone that contributes to the block and help improve the conduction through the AV node. As a result, the heart rate is expected to increase, which is a positive response to the medication.

The other options listed (B) Decrease in premature ventricular contractions, (C) Increase in strength of peripheral pulses, and (D) Decrease in premature atrial contractions, are not directly related to the effect of atropine on type 1 AV block and are not typical findings associated with atropine administration in this context. The main goal of administering atropine in this situation is to increase the heart rate and improve the AV conduction to alleviate symptoms associated with the AV block.

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A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?

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Naxlex Comprehensive Predictor Exams

Which electrocardiographic (ECG) change by a client with chest pain is most important for the nurse to report rapidly to the health care provider?

Correct Answer is D

Explanation

After the nurse gives IV atropine to a patient with symptomatic type 1. second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective?

Correct Answer is A

Explanation

The nurse teaches a student nurse about diagnostic studies used for acute coronary syndrome. Which statement made by the student nurse indicates effective learning?

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After receiving change-of-shift report on a heart failure unit, which client should the nurse assess first?

Which assessment finding of a patient with chronic kidney disease indicates to the nurse that hemodialysis is having the desired effect?

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

The nurse is reviewing the laboratory test results for a client who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?

A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?