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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A:
Choice A reason: Review the need for the UAP to wear a face mask while in close contact with the client. Influenza is a respiratory virus that spreads mainly by droplets made when people with flu cough, sneeze or talk.A face mask can help block the spread of these droplets.
Choice B reason:Reminding the UAP to apply a fitted respirator mask before entering the client’s room is not necessary for standard influenza precautions.Respirator masks are more commonly used for airborne precautions, such as tuberculosis or measles, not for influenza.
Choice C reason:Assigning the UAP to provide care for another client and assuming full care of the client is not indicated unless the UAP is not following proper infection control procedures.There is no evidence of that in the scenario provided.
Choice D reason:Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is important, but it is not the immediate action related to infection control.The priority is to prevent the spread of infection.
Correct Answer is A
Explanation
Choice A: Moderate amount of foul-smelling lochia. This is the most indicative finding of a postpartum infection, as it suggests that the client has endometritis, which is an inflammation of the uterine lining. Endometritis is a common cause of maternal morbidity and mortality, and requires prompt antibiotic treatment.
Choice B: Blood pressure of 122/74 mm Hg. This is a normal blood pressure for a postpartum client, and does not indicate an infection. The reference range for blood pressure is 90/60 to 140/90 mm Hg.
Choice C: Oral temperature of 100.2°F (37.9°C.. This is a slightly elevated temperature for a postpartum client, but it does not necessarily indicate an infection. The reference range for oral temperature is 97.6 to 99.6°F (36.4 to 37.6°C.. A mild fever may occur in the first 24 hours after delivery due to dehydration or hormonal changes.
Choice D: White blood cell count of 19,000/mm³ (19 x 10⁹/L). This is a high white blood cell count for a postpartum client, but it does not indicate an infection. The reference range for white blood cell count is 5,000 to 10,000/mm³ (5 to 10 x 10⁹/L). A leukocytosis may occur in the first few days after delivery due to stress or tissue injury.
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