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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While administering oxygen can help with overall oxygenation, it does not specifically address the issue of thick, tenacious secretions.
B. A low-salt diet might be indicated for other health concerns but does not directly impact bronchial secretions.
C. Semi-Fowler's position can help with lung expansion and ease of breathing but does not directly assist with loosening secretions.
D. Drinking 2 to 3 liters of water daily helps to thin bronchial secretions, making it easier for the client to expectorate (cough up) the mucus, which is particularly important in managing COPD.
Correct Answer is ["4"]
Explanation
To administer the correct dose of furosemide, which is 40 mg intravenously, the nurse needs to calculate the volume of furosemide solution to use. Given that the available concentration is 10 mg per 1 mL, the nurse would need 4 mL of the solution to provide the 40 mg dose. This is because the dosage required (40 mg) divided by the concentration of the solution (10 mg/mL) equals the volume to administer: 40/10= 4 mL
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