A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses?
Neck vein distention
Body weight
Abdominal girth
Blood pressure
The Correct Answer is B
a. Neck vein distention: Neck vein distention may indicate fluid overload, but it is not a direct measure of fluid losses.
b. Body weight: Monitoring body weight before and after hemodialysis provides a direct
measure of fluid losses. Hemodialysis removes excess fluid, and changes in body weight reflect fluid balance.
c. Abdominal girth: Abdominal girth may be affected by fluid accumulation but is not a direct measure of fluid losses during hemodialysis.
d. Blood pressure: While blood pressure may be influenced by fluid status, it is not a specific measure of fluid losses during hemodialysis. Body weight is a more direct indicator of fluid removal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. Paralytic ileus: Absence of bowel sounds, abdominal distention, and no passage of flatus are characteristic signs of paralytic ileus, which is a temporary impairment of bowel motility following surgery.
c. Health care-associated Clostridium difficile: Clostridium difficile infection is associated with diarrhea, abdominal pain, and fever. The absence of bowel sounds and abdominal distention is not consistent with C. difficile infection.
d. Fecal impaction: Fecal impaction is characterized by a blockage of hardened stool in the
rectum or colon, leading to difficulty passing stool. It may cause abdominal discomfort, but it does not typically present with the absence of bowel sounds and abdominal distention seen in paralytic ileus.
Correct Answer is A
Explanation
a. Determine the patency of the tubing: The first action should be to assess for any obstruction or kinks in the tubing. A blockage may be preventing the flow of urine.
b. Notify the provider: While notifying the provider may be necessary, assessing the tubing for patency is a more immediate action.
c. Offer oral fluids: While hydration is important, the priority is to ensure that the urinary catheter is functioning properly.
d. Administer a prescribed analgesic: Pain management is important postoperatively, but the
immediate concern is the lack of urinary output, which requires assessment and intervention to rule out catheter obstruction.
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