A nurse is caring for a client receiving hemodialysis.
Exhibits

A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow-up?

Vital signs

Weight

Blood glucose level

Presence of bruit and thrill

Lung sounds

AV fistula site assessment

Answer and Explanation

Correct Answer : B,E,F

A. The vital signs are stable and within normal limits. The slight drop in blood pressure post-dialysis is expected and not immediately concerning.

B. The client's weight decreased from 90 kg (198 lb) to 86.4 kg (190 lb) after dialysis. While weight loss is expected due to fluid removal during dialysis, this significant decrease (3.6 kg or approximately 8 lb) may need closer monitoring to ensure the client is not becoming dehydrated or losing more fluid than is safe.

C. The blood glucose levels are within an acceptable range for a client with type 2 diabetes mellitus. The slight decrease from 134 mg/dL to 75 mg/dL is not unusual given the time between measurements and the client's food intake.

D. The presence of a bruit and thrill at the AV fistula site indicates that it is functioning correctly, which is an expected finding.

E. The presence of crackles in the left lower lobe and an unproductive cough on the morning of Day 2 is concerning. These symptoms could indicate fluid overload or early signs of pulmonary edema, which require further evaluation and possible intervention.

F. The AV fistula site is noted to be ecchymotic and warm, with a bruit and thrill still present. While a bruit and thrill are expected findings, the ecchymosis and warmth could indicate a developing infection or trauma at the site, which necessitates further follow-up to prevent complications.

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Correct Answer is C

Explanation

A. Moist mucous membranes would indicate adequate hydration, which is not typically seen in diabetes insipidus.

B. Bounding peripheral pulses are associated with conditions of fluid overload, not diabetes insipidus.

C. Poor skin turgor is a sign of dehydration, which is a common finding in diabetes insipidus due to excessive urine output leading to significant fluid loss.

D. Bradycardia is not typically associated with diabetes insipidus; tachycardia might be seen due to dehydration and hypovolemia.

A. Reduce cholesterol and saturated fat intake. B. Sustain hyperglycemia to reduce deterioration of nerve cells. C. Maintain optimal blood pressure to prevent kidney damage. D. Increase physical activity and daily exercise. E. Enroll in a smoking cessation program.

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

Explanation

A. Reducing cholesterol and saturated fat intake is important for managing cardiovascular health, which is crucial for clients with diabetes to prevent complications such as heart disease and stroke.

B. Sustaining hyperglycemia is incorrect; it actually contributes to complications like neuropathy, retinopathy, and nephropathy. The goal is to maintain blood glucose levels within the target range.

C. Maintaining optimal blood pressure is essential in preventing diabetic nephropathy, as high blood pressure can damage the kidneys and worsen diabetic kidney disease.

D. Increasing physical activity helps improve insulin sensitivity, control blood glucose levels, and reduce the risk of complications associated with diabetes.

E. Smoking cessation is critical in reducing the risk of cardiovascular disease, which is higher in clients with diabetes. Smoking can exacerbate the complications of diabetes.

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A nurse is caring for a client receiving hemodialysis. Exhibits A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow-up?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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

Explanation

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A nurse is caring for a client receiving hemodialysis.
Exhibits

A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow-up?