A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?

The client has had a 3 lb weight gain since yesterday.

Flattened neck veins

Oxygen saturation 93%

Return of skin to previous position when the client's shin is palpated

Answer and Explanation

The Correct Answer is A

A 3 lb weight gain in a short period, especially overnight, is indicative of fluid overload in a client with end-stage kidney disease receiving hemodialysis. Hemodialysis is performed to remove excess fluid and waste products from the body. If the client is experiencing fluid overload, it means that their body is retaining more fluid than it should, and this can lead to complications such as pulmonary edema, heart failure, and other cardiovascular problems. The nurse should identify this finding as an indication of potential fluid overload and report it to the healthcare provider for further evaluation and intervention.

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Correct Answer is C

Explanation

The statement "I will call the clinic if my weight goes up 3 pounds in a week" indicates that the teaching about heart failure was effective. Monitoring weight is an essential self-care measure for patients with heart failure to manage fluid retention effectively. A sudden weight gain of 2-3 pounds in a week can indicate fluid retention and worsening heart failure. It is crucial for the patient to report such weight changes promptly to the healthcare provider or clinic to adjust medication doses or treatment plans as needed.

The other statements are incorrect:

A) "I will use the nitroglycerin patch whenever I have chest pain." Nitroglycerin is not typically used to manage heart failure. It is used for angina, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed coronary arteries.

B) "I will take furosemide (Lasix) every day just before bedtime." While furosemide is a diuretic commonly prescribed for heart failure to reduce fluid retention, it is not usually taken just before bedtime. Taking furosemide in the evening may lead to frequent nighttime urination and disrupt sleep.

D) "I will use an additional pillow if I am short of breath at night." Using an extra pillow may provide temporary relief for positional dyspnea (shortness of breath when lying flat) but is not an appropriate long-term strategy for managing heart failure. Elevated pillows may not effectively improve breathing and can lead to neck strain. Instead, patients with heart failure should be encouraged to sleep with their head slightly elevated on a regular basis, using a wedge pillow or adjustable bed if needed. Managing fluid retention and adhering to prescribed medications are essential for improving heart failure symptoms and preventing complications.

A. Heart rate 102 beats/min B. Report of chest pain C. Blood pressure 103/54 mm Hg D. Pedal pulses 1+ bilaterally

Correct Answer is C

Explanation

Among the given options, the assessment data that indicate the need for immediate action by the nurse is a blood pressure of 103/54 mm Hg. This blood pressure reading indicates hypotension, which can be concerning for a post-angioplasty patient.

Angioplasty with stent placement is an invasive procedure, and patients may experience fluctuations in blood pressure during the immediate post-operative period. Hypotension after angioplasty can be a sign of inadequate cardiac output, which may be due to issues like bleeding, fluid loss, or heart dysfunction. Inadequate blood pressure can lead to decreased perfusion to vital organs, including the heart itself, and can be life-threatening.

Options A, B, and D are also important to address:

A) Heart rate 102 beats/min: A heart rate of 102 beats per minute may indicate tachycardia, which can be expected after a procedure like angioplasty. However, it is not as urgent of a concern as hypotension, and it may be a normal compensatory response to the body's stress.

B) Report of chest pain: Chest pain after angioplasty can be common, but it should be evaluated further to ensure it is not indicative of complications such as coronary artery spasms, clot formation, or restenosis of the treated artery. While this is an important issue to address, it does not take precedence over hypotension.

D) Pedal pulses 1+ bilaterally: This finding suggests that the peripheral pulses in the feet are weak, and it could be related to the patient's medical condition, medications, or positioning. While it requires attention, it is not an immediate threat to the patient's life compared to severe hypotension.

Therefore, the nurse should prioritize assessing and addressing the low blood pressure to prevent further complications and ensure the patient's stability. The nurse should promptly notify the healthcare provider and implement appropriate interventions, such as administering intravenous fluids, to increase blood pressure to a safe level.

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A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?

Nursing Test Bank

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