The nurse in a dialysis unit is making rounds on clients. Which client should the nurse assess first?
The client with an H/H (hemoglobin and hematocrit) of 12.8 and 38.
The client who does not have a bruit or thrill in the fistula
The client who is complaining of fatigue and headache.
The client who is complaining of nausea.
The Correct Answer is B
A. The client with an H/H of 12.8 and 38 has lab values within acceptable range for a dialysis patient, especially since anemia is common in this population. This client is stable and does not require immediate assessment.
B. The client who does not have a bruit or thrill in the fistula is the priority. A lack of bruit or thrill may indicate that the arteriovenous (AV) fistula is clotted or not functioning, which is a critical issue. This compromises the client's ability to receive dialysis and requires urgent evaluation.
C. The client who is complaining of fatigue and headache may be experiencing symptoms related to uremia or hypertension, but these are not immediately life-threatening and can be addressed after checking the fistula issue.
D. The client who is complaining of nausea might be experiencing symptoms of fluid overload or uremia, but again, this is less urgent than a potentially non-functioning dialysis access site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Glomerulonephritis usually presents with symptoms such as facial edema, hypertension, and dark (cola-colored) urine. It is not typically associated with sharp, radiating pain or known obstructive renal calculi.
B. Hydronephrosis is the correct Answer. It occurs when a urinary tract obstruction (such as a 6 mm renal calculus) leads to urine buildup and swelling in the kidney. The client’s sharp, radiating pain, hematuria, and presence of leukocytes in the urine strongly support this diagnosis.
C. Inguinal hernia may cause groin pain or bulging, but does not explain hematuria, leukocyturia, or the findings of an obstructive renal stone.
D. Posterior urethral valvitis is a rare congenital condition typically seen in male infants and young boys, not in a 47-year-old adult male, making it an unlikely diagnosis.
Correct Answer is D
Explanation
A. Cold sweats are more commonly associated with hypoglycemia, not DKA.
B. Bradycardia (slow heart rate) is not a typical finding in DKA, where tachycardia is more likely due to dehydration.
C. Cyanosis (bluish discoloration) is seen in severe respiratory or cardiac conditions, not a hallmark of DKA.
D. Kussmaul respirations (deep, rapid breathing) are a hallmark sign of DKA. They represent the body’s attempt to compensate for metabolic acidosis by blowing off excess CO₂.
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