A nurse is caring for a client receiving hemodialysis.
A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow-up? Select all that apply.
Lung sounds
AV fistula site assessment
Blood glucose level
Weight
Vital signs
Presence of bruit and thrill
Correct Answer : A,B,C,D,E
A. Lung sounds: On Day 1, lungs were clear. By Day 2 at 0700, the client has crackles in the left lower lobe and an unproductive cough. This indicates fluid moving into the lungs (pulmonary edema), suggesting the client is retaining fluid or that dialysis did not remove enough volume.
B. AV fistula site assessment: Ecchymosis and warmth at the AV fistula site suggest potential trauma, hematoma formation, or infection. Any changes in the site after dialysis require prompt evaluation to prevent complications such as thrombosis or infection.
C. Blood glucose level: The client’s glucose dropped to 75 mg/dL, which is at the lower end of normal. Clients with diabetes on dialysis are at risk for hypoglycemia due to fluid and nutrient shifts, requiring monitoring and possible intervention.
D. Weight: Monitoring post-dialysis weight is essential to assess fluid removal. Any unexpected weight gain or inadequate fluid removal could indicate problems with dialysis effectiveness or fluid management, necessitating follow-up.
E. Vital signs: The blood pressure dropped from 144/72 mm Hg pre-dialysis to 112/54 mm Hg post-dialysis, which may indicate intradialytic hypotension. Significant changes in vital signs require evaluation to prevent hypoperfusion and related complications.
F. Presence of bruit and thrill: The AV fistula continues to have a palpable thrill and audible bruit, indicating patency. This is an expected finding and does not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1","780"]
Explanation
Calculation:
- Identify and convert all intake to mL
0.9% sodium chloride IV solution = 1,000 mL
Coffee (8 oz) = 8 × 30 = 240 mL
Water (6 oz) = 6 × 30 = 180 mL
Soup = 180 mL
Flavored gelatin (3 oz) = 3 × 30 = 90 mL
Ice cream (3 oz) = 3 × 30 = 90 mL
- Add all volumes together
Total Intake = 1,000 + 240 + 180 + 180 + 90 + 90
= 1,780 mL
Correct Answer is B
Explanation
A. Continue routine care because the results are within the expected reference range: The client’s BUN (32 mg/dL) and hematocrit (50%) are elevated, indicating possible dehydration. Continuing routine care without further assessment could overlook fluid imbalance and kidney stress.
B. Evaluate urine output for amount and urine for specific gravity: Monitoring urine output and specific gravity helps assess kidney perfusion and hydration status. Elevated BUN and hematocrit suggest intravascular volume depletion, so assessing renal function and urine concentration is a critical next step to guide fluid therapy.
C. Decrease the IV fluid infusion rate and limit oral fluid intake: Reducing fluids in a client showing signs of dehydration would worsen intravascular volume deficit. The client requires careful monitoring and likely continuation or adjustment of IV fluids to restore adequate hydration.
D. Collect a urine specimen for culture and sensitivity: There is no indication of a urinary tract infection in the scenario. While urine testing is important in infection, it is not the priority action when signs point toward dehydration and volume depletion.
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