A nurse is caring for a client receiving hemodialysis.
Exhibits
A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow-up?
Vital signs
Weight
Blood glucose level
Presence of bruit and thrill
Lung sounds
AV fistula site assessment
Correct Answer : B,E,F
A. The vital signs are stable and within normal limits. The slight drop in blood pressure post-dialysis is expected and not immediately concerning.
B. The client's weight decreased from 90 kg (198 lb) to 86.4 kg (190 lb) after dialysis. While weight loss is expected due to fluid removal during dialysis, this significant decrease (3.6 kg or approximately 8 lb) may need closer monitoring to ensure the client is not becoming dehydrated or losing more fluid than is safe.
C. The blood glucose levels are within an acceptable range for a client with type 2 diabetes mellitus. The slight decrease from 134 mg/dL to 75 mg/dL is not unusual given the time between measurements and the client's food intake.
D. The presence of a bruit and thrill at the AV fistula site indicates that it is functioning correctly, which is an expected finding.
E. The presence of crackles in the left lower lobe and an unproductive cough on the morning of Day 2 is concerning. These symptoms could indicate fluid overload or early signs of pulmonary edema, which require further evaluation and possible intervention.
F. The AV fistula site is noted to be ecchymotic and warm, with a bruit and thrill still present. While a bruit and thrill are expected findings, the ecchymosis and warmth could indicate a developing infection or trauma at the site, which necessitates further follow-up to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. It is essential to keep the drainage system below the level of the client's chest to prevent backflow of fluid into the pleural space, which could lead to complications such as a pneumothorax.
B. Clamping the chest tube is generally not recommended during transport because it can lead to a buildup of pressure in the pleural space, increasing the risk of a tension pneumothorax.
C. Disconnecting the chest tube from the drainage system is not advisable, as this could lead to air entering the pleural space, causing a pneumothorax.
D. Emptying the collection chamber is not necessary prior to transport, and it could lead to inaccurate measurement of fluid output. The focus should be on ensuring that the system remains intact and below chest level during transport.
Correct Answer is ["A","B","D","E"]
Explanation
Rationale:
A. Purple striae (stretch marks) are common in Cushing's syndrome due to skin thinning and the redistribution of fat.
B. A "moon face" is a classic sign of Cushing's syndrome, caused by fat deposition in the face.
C. Bronze pigmentation is associated with Addison's disease, not Cushing's syndrome.
D. A "buffalo hump," or fat accumulation on the upper back, is another characteristic feature of Cushing's syndrome.
E. Poor wound healing is expected in Cushing's syndrome due to the effects of prolonged exposure to high cortisol levels, which impair immune function and tissue repair.
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