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 C
Explanation
Choice A reason: This is incorrect because 18% is the percentage of body surface area for the entire anterior trunk, not just the lower extremities.
Choice B reason: This is incorrect because 45% is the percentage of body surface area for the entire anterior and posterior trunk, plus the head and neck, not just the lower extremities.
Choice C reason: This is correct because 9% is the percentage of body surface area for the anterior surfaces of both lower extremities, according to the rule of nines.
Choice D reason: This is incorrect because 36% is the percentage of body surface area for the entire anterior and posterior surfaces of both lower extremities, not just the anterior surfaces.
Correct Answer is B
Explanation
Choice B reason: the client with antisocial behavior is at risk of being harmed by other clients or harming others. The nurse should intervene immediately to prevent violence and ensure safety.
Choice A reason: the client with anorexia nervosa who is refusing to eat the evening snack is not in immediate danger. The nurse should monitor the client's nutritional status and weight, but this can be done later.
Choice C reason: the client with bipolar disorder who is pacing around the lobby is not in immediate danger. The nurse should assess the client's mood and energy level, but this can be done later.
Choice D reason: the client with major depression who refuses to participate in group is not in immediate danger. The nurse should encourage the client to join the group, but this can be done later.
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