A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available for use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement?
Serum Albumin Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)
Recommend the use of support stockings to enhance venous return
Ensure the client receives frequent small meals containing complete proteins
Evaluate patency of the AV graft for resumption of hemodialysis
Instruct the client to continue to follow the prescribed rigid fluid restriction amounts
The Correct Answer is B
Choice A reason: Support stockings may help with peripheral edema, but they are not the priority intervention for this client. The client's low serum albumin level indicates malnutrition and increased risk of infection and poor wound healing.
Choice B reason: This is the correct answer because the client needs adequate protein intake to maintain serum albumin levels and prevent further complications. Complete proteins contain all nine essential amino acids that the body cannot synthesize and are found in animal sources such as meat, eggs, and dairy products.
Choice C reason: Evaluating patency of the AV graft is not the priority intervention for this client because the client is receiving peritoneal dialysis, not hemodialysis. The AV graft may be used in the future if peritoneal dialysis fails, but it is not an immediate concern.
Choice D reason: Instructing the client to follow fluid restriction amounts is important for peritoneal dialysis patients, but it is not the priority intervention for this client. The client's low serum albumin level indicates that fluid restriction alone is not sufficient to manage fluid balance and prevent edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["4"]
Explanation
To convert pounds to kilograms, divide by 2.2.
44 pounds / 2.2 = 20 kg
To find the dose of furosemide in mg, multiply the weight in kg by the dosage in mg/kg.
20 kg x 2 mg/kg = 40 mg
To find the volume of furosemide in mL, divide the dose in mg by the concentration in mg/mL.
40 mg / 10 mg/mL = 4 mL
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: This is incorrect because providing a diet low in phosphorus is not indicated for a client with cirrhosis of the liver. Phosphorus restriction is more relevant for clients with renal failure, not liver failure.
Choice B reason: This is correct because noting signs of swelling and edema is an essential intervention for a client with cirrhosis of the liver. Swelling and edema are signs of fluid retention and portal hypertension, which are common complications of liver disease.
Choice C reason: This is incorrect because increasing oral fluid intake to 1,500 mL daily is not advisable for a client with cirrhosis of the liver. Fluid restriction may be necessary to prevent fluid overload and ascites, which are common complications of liver disease.
Choice D reason: This is correct because monitoring abdominal girth is an important intervention for a client with cirrhosis of the liver. Abdominal girth measurement can indicate the presence and severity of ascites, which is a common complication of liver disease.
Choice E reason: This is correct because reporting serum albumin and globulin levels is a vital intervention for a client with cirrhosis of the liver. Serum albumin and globulin levels can reflect the liver's synthetic function and indicate the extent of liver damage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today