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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A rationale
A red and beefy tongue is not a symptom of digoxin toxicity. This symptom is more commonly associated with vitamin B12 deficiency or other nutritional deficiencies.
Choice B rationale
Constipation is not a typical symptom of digoxin toxicity. Digoxin toxicity primarily affects the gastrointestinal system with symptoms such as nausea, vomiting, and diarrhea, rather than causing constipation.
Choice C rationale
Yellow vision, or xanthopsia, is a classic symptom of digoxin toxicity. Digoxin can cause visual disturbances, including seeing halos around lights and a yellow tint to vision, due to its effects on the optic nerve.
Choice D rationale
Gaining weight is not a symptom of digoxin toxicity. Weight gain is more commonly associated with fluid retention in conditions such as heart failure, which digoxin is used to treat.
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