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 A

Explanation

A. It is essential to keep the drainage system below the level of the client's chest to prevent backflow of fluid into the pleural space, which could lead to complications such as a pneumothorax.

B. Clamping the chest tube is generally not recommended during transport because it can lead to a buildup of pressure in the pleural space, increasing the risk of a tension pneumothorax.

C. Disconnecting the chest tube from the drainage system is not advisable, as this could lead to air entering the pleural space, causing a pneumothorax.

D. Emptying the collection chamber is not necessary prior to transport, and it could lead to inaccurate measurement of fluid output. The focus should be on ensuring that the system remains intact and below chest level during transport.

A. Increase in weight B. Decrease in body temperature C. Increase in energy D. Decreased heart rate

Correct Answer is C

Explanation

A. An increase in weight is typically a symptom of untreated or poorly managed hypothyroidism, not a therapeutic response.

B. A decrease in body temperature is associated with hypothyroidism, and an improvement in this condition should result in a normalization of temperature, not a decrease.

C. An increase in energy is a therapeutic response to liothyronine, as hypothyroidism often causes fatigue and low energy levels. Treatment with liothyronine should alleviate these symptoms and restore normal energy levels.

D. A decreased heart rate (bradycardia) is a symptom of hypothyroidism, and effective treatment should normalize the heart rate, not lower it further.

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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

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Correct Answer is A

Explanation

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Correct Answer is C

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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?