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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
LDL (low-density lipoprotein) levels are relevant to cardiovascular risk assessment but not directly impacted by warfarin therapy, making it irrelevant for monitoring its effects.
Choice B rationale
BUN (blood urea nitrogen) reflects renal function but does not indicate coagulation status. Therefore, it is not a parameter used to guide warfarin therapy.
Choice C rationale
Hct (hematocrit) represents the proportion of red blood cells in blood and is unrelated to monitoring anticoagulation therapy. It does not reflect warfarin's therapeutic effects.
Choice D rationale
INR (international normalized ratio) measures blood coagulation and is used to monitor warfarin efficacy. Maintaining therapeutic INR prevents thromboembolic events and minimizes bleeding risks. A target INR range for atrial fibrillation is typically 2.0 to 3.0.
Correct Answer is C
Explanation
Choice A rationale
Setting the indoor temperature at 17°C (64°F) is too low for older adults, increasing their risk for hypothermia. A higher indoor temperature is recommended for safety.
Choice B rationale
Low-carbohydrate diets are not ideal in preventing hypothermia. Carbohydrates are essential for energy production and thermoregulation, especially in colder weather.
Choice C rationale
Covering the head is critical as significant heat loss occurs through the head. This practice helps conserve body heat during colder temperatures.
Choice D rationale
Wearing a single layer is insufficient for retaining body heat in winter. Layering clothing provides insulation by trapping warm air, which helps prevent hypothermia. .
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