A nurse is caring for a client who has undergone hemodialysis. Which of the following findings should the nurse report to the provider?
Decrease in weight
Headache
Fatigue
Vibration at fistula site
The Correct Answer is B
A. Decrease in weight: A reduction in weight after hemodialysis is expected due to removal of excess fluid. This finding indicates the procedure is effectively managing fluid overload and does not require immediate reporting.
B. Headache: Headaches can indicate rapid shifts in fluid and electrolytes during or after dialysis, sometimes signaling dialysis disequilibrium syndrome or other complications. Prompt reporting allows timely assessment and intervention to prevent worsening neurological symptoms.
C. Fatigue: Mild fatigue is common following hemodialysis due to fluid shifts and changes in blood pressure. This is typically self-limiting and expected, so it does not require urgent reporting.
D. Vibration at fistula site: A palpable thrill or vibration at the arteriovenous fistula is expected and indicates patency. This is a normal finding and does not warrant reporting to the provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "You will be able to eat as soon as the procedure is finished.": After a bronchoscopy, the gag reflex may be temporarily suppressed due to local anesthesia. Clients should not eat or drink until the reflex returns to prevent aspiration.
B. "You should not eat or drink for 2 hours before the scheduled time of the procedure.": Fasting is generally required for 6–8 hours before a bronchoscopy to reduce the risk of aspiration during sedation, not just 2 hours. Clear instructions on proper fasting are important.
C. "You will be placed on your left side during the procedure.": The client is usually positioned supine or semi-reclined to allow optimal access to the airway. Side-lying is not standard for bronchoscopy and may compromise visualization.
D. "Your vital signs will be checked frequently for the first 2 hours after the procedure.": Monitoring vital signs post-procedure is essential because sedation and airway manipulation can lead to complications such as hypoxia, bleeding, or respiratory distress. Frequent assessment ensures early detection and intervention.
Correct Answer is B
Explanation
A. "I will wear an arm immobilizer to prevent dislodgement of this device.": Arm immobilizers are not required for PICC lines. Gentle activity and avoiding heavy lifting on the affected arm are sufficient to prevent dislodgement without restricting normal movement.
B. "I will monitor my temperature for fever while I have this device.": Monitoring for fever is essential because a PICC line increases the risk of bloodstream infections. Early detection of infection allows prompt intervention, reducing complications associated with chemotherapy and central line use.
C. "It's okay to get the device wet when I shower.": PICC lines must be kept dry to prevent infection. Clients should cover the site with a waterproof dressing or follow facility-specific guidelines during bathing to maintain sterility.
D. "I should pull the dressing away from the insertion site when I change it.": Dressings should never be pulled directly off the insertion site as this can dislodge the catheter and increase infection risk. Proper technique involves gently lifting edges and following sterile procedures.
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