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","D","E"]

Explanation

A. Bradycardia is not typically associated with emphysema; tachycardia is more common due to hypoxia.
B. Deep respirations are not a hallmark of emphysema; patients often have shallow, rapid breathing due to decreased lung capacity.
C. A barrel chest is a characteristic sign of emphysema, resulting from hyperinflation of the lungs over time.
D. Clubbing of the fingers can occur due to chronic hypoxia associated with emphysema.
E. Dyspnea, or difficulty breathing, is a primary symptom of emphysema due to the destruction of alveoli and reduced gas exchange.

A. "Are you experiencing pain in your joints?" B. “Do you have tremors in your hands?" C. “Do you notice any swelling in your legs at night.” D. “Have you had problems with diarrhea lately?”

Correct Answer is A

Explanation

A. Hyperparathyroidism often leads to elevated levels of calcium in the blood, which can result in joint and bone pain due to the excessive breakdown of bone tissue (osteoporosis).

B. Tremors are not typically associated with hyperparathyroidism; they are more commonly linked to conditions like hyperthyroidism or neurological disorders.

C. Swelling in the legs is more commonly associated with conditions like heart failure or venous insufficiency, not hyperparathyroidism.

D. Diarrhea is not a common symptom of hyperparathyroidism; this condition is more likely to cause constipation due to hypercalcemia.

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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 caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

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

Explanation

The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition?

Correct Answer is A

Explanation

The nurse assessing a client hospitalized with a diagnosis of hypoparathyroidism notes positive Trousseau's and Chvostek's signs. The nurse determines that these findings most indicate which electrolyte imbalance?

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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?