A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?

Take the client to the emergency department (ED)

Apply the client's home oxygen

Ensure that the client avoids salt intake for the rest of the day

Check for a thrill and bruit at the client's dialysis access site

Answer and Explanation

The Correct Answer is A

Choice A reason: Taking the client to the emergency department is crucial because missing a dialysis session can lead to severe complications such as fluid overload, high potassium levels, and other electrolyte imbalances. These conditions can be life-threatening and require immediate medical attention to stabilize the client.

Choice B reason: Applying home oxygen is not the most critical intervention in this scenario. While oxygen therapy might be necessary in some cases, it does not address the immediate risk of complications arising from missed dialysis.

Choice C reason: Ensuring that the client avoids salt intake for the rest of the day is important for managing fluid balance, but it is not the most urgent action needed in this situation. The client's lethargy and difficulty arousing indicate a more serious underlying issue that requires immediate medical evaluation.

Choice D reason: Checking for a thrill and bruit at the client's dialysis access site is important for assessing the patency of the access site, but it is not the most critical action in this scenario. The immediate concern is the client's lethargy and potential complications from missed dialysis, which necessitate emergency medical care.

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Correct Answer is C

Explanation

Choice A reason: Ensuring the IV solution is infusing at the prescribed rate is important, but it is not the first action the nurse should take. The symptoms the client is exhibiting—low blood pressure, tachycardia, restlessness, and irritability—are indicative of potential hypovolemic shock, likely due to bleeding. Immediate assessment for bleeding is more critical.

Choice B reason: Notifying the healthcare provider of the findings is essential, but it should be done after assessing the client for signs of bleeding. The nurse needs to quickly identify the source of the client’s symptoms before contacting the healthcare provider to provide a complete and accurate report of the situation.

Choice C reason: Checking under the back for evidence of bleeding is the correct first action. The client's symptoms suggest they might be experiencing hypovolemic shock due to postoperative bleeding. Identifying whether there is visible bleeding can help determine the next steps in managing the client's condition and providing appropriate interventions.

Choice D reason: Listening to lung sounds is important in a comprehensive assessment but is not the priority in this scenario. The client's symptoms strongly indicate a potential bleeding issue, so checking for evidence of bleeding should come first to promptly address the most life-threatening concern.

Correct Answer is ["400"]

Explanation

Step-by-Step Calculation:

Step 1: Determine the total volume to be infused 100 mL

Step 2: Convert minutes to hours 15 minutes ÷ 60 minutes per hour = 0.25 hours

Step 3: Calculate the infusion rate in mL/hr 100 mL ÷ 0.25 hours = 400 mL/hr

Answer: 400 mL/hr

So, the nurse should program the infusion pump to deliver 400 mL/hr.

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A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

Correct Answer is C

Explanation

The healthcare provider prescribes 100 mL of 0.9% normal saline to be infused within 15 minutes. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

Correct Answer is ["400"]

Explanation

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