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.

Vibration at fistula site.

Headache.

Fatigue.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A decrease in weight is common post-hemodialysis due to fluid removal. This is usually anticipated and does not require immediate reporting unless there are other associated symptoms or unusual weight patterns indicating fluid imbalance.

Choice B rationale

Vibration at the fistula site, known as a thrill, indicates proper functioning of the arteriovenous fistula. This finding is expected and does not necessitate urgent communication unless there are other complications.

Choice C rationale

Headache following hemodialysis may indicate fluid shifts, electrolyte imbalances, or other underlying problems. It should be reported to the provider for further evaluation and possible intervention to address these concerns.

Choice D rationale

Fatigue is a common post-hemodialysis symptom due to the physiological stress of the procedure. While expected, its severity should be evaluated in the context of other findings to determine if it needs attention.

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Correct Answer is C

Explanation

Choice A rationale

Instilling saline into the tubing is not recommended as it increases infection risks and does not clear secretions effectively. It is contraindicated in tracheostomy care and can harm the patient’s respiratory system.

Choice B rationale

Checking the cuff pressure is essential to prevent complications like tracheal injury or air leaks. However, it does not directly alleviate restlessness or crackles in the lungs caused by secretions.

Choice C rationale

Performing suctioning removes secretions from the tracheostomy tube and airways, improving oxygenation and reducing lung crackles. It is the most effective immediate intervention for this scenario.

Choice D rationale

Increasing humidification prevents secretion thickening but does not address accumulated secretions already causing crackles and respiratory distress.

A. Encourage the client to talk with another client who completed rehabilitation for amputation. B. Ask the client to describe her feelings about the loss of the affected limb. C. Suggest that family members bring clothing for the client from home. D. Restrict visitors to family members until the client is able to wear a prosthesis.

Correct Answer is A

Explanation

Choice A rationale

Discussing the experience with another person who has undergone rehabilitation fosters peer support and may normalize feelings. This intervention uses the principle of modeling, which is effective in rehabilitation psychology. Peer interactions help build coping strategies and adaptive behaviors. This psychological framework encourages emotional recovery and acceptance of body image changes.

Choice B rationale

While discussing feelings is essential, it is not an intervention but part of psychosocial assessment. Focusing solely on verbalizing feelings might delay action-oriented coping mechanisms. Emotional processing can benefit from structured therapeutic dialogue.

Choice C rationale

Bringing clothing may enhance familiarity with surroundings, but it does not directly address emotional adjustment or acceptance of amputation. Prioritizing interventions with stronger psychological impact is more beneficial in initial rehabilitation phases.

Choice D rationale

Restricting visitors impairs social support, which is essential for emotional well-being. Alienation may heighten feelings of isolation or depression. Evidence supports family involvement in recovery, not exclusion.

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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

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Explanation

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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?