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.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A: Observing the insertion site of the suprapubic catheter is an essential assessment for the home health nurse, as this can help detect any signs of infection, inflammation, or leakage. Therefore, this is the correct choice.

Choice B: Palpating the flank area is not a necessary assessment for the home health nurse, as this is not related to the suprapubic catheter. This is a distractor choice.

Choice C: Measuring abdominal girth is not a relevant assessment for the home health nurse, as this is not affected by the suprapubic catheter. This is another distractor choice.

Choice D: Assessing the perineal area is not an important assessment for the home health nurse, as this is not involved in the suprapubic catheter. This is another distractor choice.

A. Discuss the issue privately with the UAP. B. Note date and time of the behavior. C. Plan for scheduled break times. D. Evaluate the UAP for signs of improvement.

Correct Answer is B,A,C,D

Explanation

The correct order is:

- Note date and time of the behavior.

- Discuss the issue privately with the UAP.

- Plan for scheduled break times.

- Evaluate the UAP for signs of improvement.

Here are the reasons for this order:

- Note date and time of the behavior. This should be done first, as it can provide objective evidence of the UAP's behavior and its impact on patient care and staff workload. The unit manager should document any incidents or complaints related to the UAP's behavior in a factual manner.

- Discuss the issue privately with the UAP. This should be done second, as it can provide an opportunity for feedback and clarification. The unit manager should use a respectful and professional tone, and explain how the UAP's behavior affects patient safety and staff morale. The unit manager should also listen to any concerns or challenges that the UAP may have, and offer support or guidance as needed.

- Plan for scheduled break times. This should be done third, as it can provide a solution or prevention strategy for future occurrences. The unit manager should work with the UAP and other staff members to ensure that there are adequate breaks and coverage for patient care. The unit manager should also review any policies or procedures related to break times and staff attendance.

- Evaluate the UAP for signs of improvement. This should be done last, as it can provide a measure of effectiveness and accountability. The unit manager should monitor and document any changes in the UAP's behavior, performance, or attitude. The unit manager should also provide positive reinforcement or corrective action as appropriate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is A

Explanation

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Correct Answer is B,A,C,D

Explanation

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