A client is receiving continuous ambulatory peritoneal dialysis (CAPD. and the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has serum albumin level at 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement?

Reference Range
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.

Answer and Explanation

The Correct Answer is B

Choice A: Recommending the use of support stockings to enhance venous return is not a priority intervention for the nurse, as this does not address the underlying cause of the peripheral edema, which is fluid overload due to inadequate dialysis. This is a distractor choice.

Choice B: Ensuring the client receives frequent small meals containing complete proteins is a priority intervention for the nurse, as this can help improve the client's nutritional status and increase their serum albumin level, which can reduce fluid leakage into the interstitial spaces and decrease edema. Therefore, this is the correct choice.

Choice C: Evaluating patency of the AV graft for resumption of hemodialysis is not a priority intervention for the nurse, as this is not feasible at this point since the AV graft is no longer available to use. This is another distractor choice.

Choice D: Instructing the client to continue to follow the prescribed rigid fluid restriction amounts is not a priority intervention for the nurse, as this does not address the root problem of inadequate dialysis and low serum albumin level, which are contributing to fluid overload and edema. This is another distractor choice.

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Correct Answer is D

Explanation

Choice A reason: Securing chest tube to the stretcher for transport is not the most important action for the nurse to take. Chest tube is a device that drains air or fluid from the pleural space or mediastinum after surgery or trauma. Securing chest tube to the stretcher can prevent accidental dislodgement or kinking of the tube during transport, but it is not as crucial as maintaining proper drainage.

Choice B reason: Administering PRN pain medication prior to transport is not the most important action for the nurse to take. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Administering pain medication prior to transport can improve comfort and reduce anxiety for the client, but it is not as urgent as preventing complications.

Choice C reason: Marking the amount of chest drainage on the container is not the most important action for the nurse to take. Chest drainage is the fluid or air that collects in the chest tube container after being drained from the pleural space or mediastinum. Marking the amount of chest drainage on the container can help monitor fluid balance and detect excessive bleeding or leakage, but it is not as vital as ensuring proper drainage.

A. Ensure that the infant's crib mattress is firm. B. Prop the infant with a pillow when in a side-lying position. C. Swaddle the infant in a blanket for sleeping. D. Place the infant in a prone position whenever possible.

Correct Answer is A

Explanation

Choice A reason: This is correct because a firm mattress reduces the risk of suffocation and rebreathing of carbon dioxide, which are associated with SIDS.

Choice B reason: This is incorrect because propping the infant with a pillow can cause the infant to slide down and suffocate or obstruct the airway.

Choice C reason: This is incorrect because swaddling the infant in a blanket can cause overheating, which is a risk factor for SIDS.

Choice D reason: This is incorrect because placing the infant in a prone position can increase the risk of SIDS by impairing gas exchange and thermoregulation.

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Naxlex Comprehensive Predictor Exams

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

Correct Answer is D

Explanation

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Correct Answer is A

Explanation

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply)

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to ask in the assessment of this client?