A nurse is assisting with the care of a client who has hypertension and chronic kidney disease. The client is scheduled for hemodialysis. Which of the following actions should the nurse plan to take while caring for this client? (Select all that apply.)

Obtain the client’s weight.

Verify the glomerular filtration rate.

Check the graft site for a palpable thrill.

Document vital signs.

Administer a sedative to the client.

Answer and Explanation

Correct Answer : A,C,D

The correct answers are Choices A, C, and D.

Choice A rationale: Obtaining the client's weight is important before and after hemodialysis to assess fluid removal and monitor the patient's fluid balance.

Choice B rationale: Verifying the glomerular filtration rate (GFR) is not necessary immediately before hemodialysis. GFR is typically assessed periodically to monitor kidney function but is not required for each dialysis session.

Choice C rationale: Checking the graft site for a palpable thrill is essential to ensure the arteriovenous (AV) fistula or graft is functioning properly. The thrill indicates that blood is flowing through the access site.

Choice D rationale: Documenting vital signs is crucial before, during, and after hemodialysis to monitor the client's hemodynamic status and detect any complications.

Choice E rationale: Administering a sedative is not a routine part of hemodialysis care. Sedatives may be prescribed for specific situations, but it is not standard practice.

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Correct Answer is D

Explanation

Choice A rationale
Positioning the lower extremities so that they are touching is incorrect because it can lead to adduction of the hip, which increases the risk of dislocation. After a total hip arthroplasty, it is important to maintain proper alignment of the hip joint to prevent dislocation. Keeping the legs apart with the use of an abduction pillow or wedge is recommended to maintain proper alignment and reduce the risk of complications.
Choice B rationale

Ensuring that the client’s heels are touching the bed is incorrect because it can lead to pressure ulcers. After a total hip arthroplasty, it is important to prevent pressure on the heels by using pillows or heel protectors to elevate the heels off the bed. This helps to reduce the risk of pressure ulcers and promotes better circulation to the lower extremities.
Choice C rationale
Instructing the client to avoid movement of the affected leg is incorrect because early mobilization is important for recovery. After a total hip arthroplasty, patients are encouraged to perform gentle exercises and mobilize as soon as possible to prevent complications such as deep vein thrombosis (DVT) and to promote healing. Immobilization can lead to stiffness, muscle atrophy, and other complications.
Choice D rationale
Preventing hip flexion of the affected extremity is correct because excessive hip flexion can increase the risk of dislocation. After a total hip arthroplasty, it is important to avoid positions that involve hip flexion greater than 90 degrees, such as sitting in low chairs or bending forward excessively. Maintaining proper hip precautions helps to reduce the risk of dislocation and promotes a safe recovery.

A. Frothy sputum. B. Orthopnea. C. Dyspnea. D. Peripheral edema.

Correct Answer is D

Explanation

Choice A rationale
Frothy sputum is more commonly associated with left-sided heart failure, where fluid backs up into the lungs. It is not a typical finding in right-sided heart failure.
Choice B rationale

Orthopnea, or difficulty breathing while lying flat, is more commonly associated with left-sided heart failure. Right-sided heart failure primarily affects the systemic circulation.
Choice C rationale
Dyspnea, or shortness of breath, can occur in both left-sided and right-sided heart failure. However, it is more prominently associated with left-sided heart failure.
Choice D rationale
Peripheral edema, or swelling in the legs and ankles, is a common finding in right-sided heart failure. It occurs due to the backup of blood in the systemic circulation, leading to fluid accumulation in the tissues.

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A nurse is assisting with the care of a client who has hypertension and chronic kidney disease. The client is scheduled for hemodialysis. Which of the following actions should the nurse plan to take while caring for this client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about monitoring weight with a client who has chronic kidney disease. Which of the following instructions should the nurse include in the teaching?

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