A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

Obtain a complete blood count (CBC)

Start IV fluids

Apply direct pressure

Administer pain medication

Answer and Explanation

The Correct Answer is C

A. Obtain a complete blood count (CBC): This is not the immediate action in an active bleeding scenario.

B. Start IV fluids: This may be needed later if significant blood loss occurs, but not the first response.

C. Apply direct pressure: Bleeding from a fistula requires immediate direct pressure to prevent blood loss and preserve vascular access.

D. Administer pain medication: Pain management is important but not the priority in acute bleeding.

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Correct Answer is B

Explanation

A. Bradycardia: Peritonitis is usually associated with tachycardia, not bradycardia.

B. Nausea and vomiting: These are common early signs of peritonitis, often accompanied by abdominal pain and fever.

C. Increased urinary output: Clients with peritoneal dialysis often have reduced kidney function, so urine output is generally decreased, not increased.

D. Hyperactive bowel sounds: Bowel sounds are usually diminished or hypoactive in peritonitis due to inflammation.

A. Assessing psychosocial coping B. Adequate fluid resuscitation C. Provide nutritional support D. Mitigating risk of infection

Correct Answer is B

Explanation

A. Assessing psychosocial coping:
Important, but not a priority in the early acute phase, when survival is the focus.

B. Adequate fluid resuscitation:
Major burns lead to capillary leakage and hypovolemia. Fluid resuscitation prevents shock and organ failure.

C. Provide nutritional support:
Necessary but becomes more relevant in the later stages after fluid and hemodynamic stability are achieved.

D. Mitigating risk of infection:
Infection control is vital but comes after fluid volume replacement in prioritization.

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A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?

Correct Answer is B

Explanation

A client has been admitted to a burn intensive care unit with extensive full thickness burns over 36% of the body. After ensuring cardiopulmonary stability, which should be the nurse's highest priority when planning the client's care in the early acute phase of the injury?

Correct Answer is B

Explanation

A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?

A nurse is caring for a client receiving sodium polystyrene sulfonate (Kayexalate) for the treatment of chronic renal disease. The nurse should monitor for which therapeutic effect of sodium polystyrene sulfonate (Kayexalate)?

A nurse is caring for a client receiving a hemodialysis treatment. Which of the following complications should the nurse recognize when the client becomes restless and reports nausea and headache?

A nurse is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

A nurse is teaching a client diagnosed with chronic kidney disease (CKD) about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)