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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Administer a laxative: A laxative can increase fluid loss through the intestines, worsening dehydration and concentrating serum sodium levels even further. Hypernatremia often results from fluid deficit, so additional fluid loss would aggravate the imbalance.

B. Restrict sodium intake: Limiting dietary sodium helps reduce further increases in serum sodium levels and supports correction of the imbalance. This intervention works alongside fluid replacement to gradually normalize sodium concentration. It also prevents exacerbation of neurologic symptoms associated with hypernatremia.

C. Restrict fluid intake: Reducing fluid intake would cause serum sodium levels to rise further by increasing concentration. Hypernatremia typically requires careful fluid replacement to restore balance, not restriction. Limiting fluids would worsen dehydration and delay recovery.

D. Administer a potassium supplement: Potassium levels are not directly addressed when managing hypernatremia unless there is a documented deficit. Supplementing potassium without evidence of hypokalemia adds unnecessary risk and does not contribute to correcting high sodium levels.

A. "I should limit my conversation with the client while wearing my mask." B. "After completing the suctioning. I should remove my gloves." C. "I will need to wear an N95 respiratory mask while suctioning the client." D. "I will pull the glove cuff over the wrist of the gown."

Correct Answer is C

Explanation

A. "I should limit my conversation with the client while wearing my mask.": Limiting unnecessary talking reduces the risk of mask contamination and prevents droplets from escaping around the mask. This reflects safe practice when working close to the airway during suctioning.

B. "After completing the suctioning, I should remove my gloves.": Gloves are removed first because they are the most contaminated item after suctioning. Taking them off immediately helps prevent cross-contamination and maintains correct PPE removal order. This shows appropriate understanding of PPE technique.

C. "I will need to wear an N95 respiratory mask while suctioning the client.": An N95 mask is not required for community-acquired pneumonia because it is transmitted by droplets, not airborne particles. A surgical mask provides adequate protection for droplet precautions. This statement shows misunderstanding and indicates a need for further teaching.

D. "I will pull the glove cuff over the wrist of the gown.": This technique prevents skin exposure and creates a proper seal between the glove and gown. It reduces the risk of contamination during suctioning procedures.

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A nurse is caring for a client who has undergone hemodialysis. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has hypernatremia. Which of the following interventions should the nurse recommend to include in the plan?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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