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?

To determine the correct dosage of albuterol syrup, the nurse needs to perform a simple calculation. The prescription requires 1.6 mg of albuterol per dose. With the available concentration of 2 mg per 5 mL, the nurse can calculate the volume of syrup needed by setting up a proportion: (2 mg / 5 mL = 1.6 mg / X mL). Solving for X gives us (1.6 mg * 5 mL) / 2 mg, which equals 4 mL.

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.