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. Slow, steady bubbling in the suction control chamber indicates that the system is functioning correctly. The nurse should continue to monitor the client's respiratory status and the drainage system.
B. Clamping the chest tube is not indicated unless instructed by the healthcare provider, as it could lead to a dangerous buildup of pressure in the pleural space.
C. Checking the suction control outlet on the wall is not necessary if the suction control chamber is already bubbling steadily.
D. Checking the tubing connections for leaks is unnecessary if the bubbling is slow and steady, as this indicates the system is working properly.
Correct Answer is B
Explanation
A. Bubbling in the water seal chamber with exhalation can be normal as it indicates air is escaping from the pleural space; however, continuous bubbling may indicate an air leak and would need to be assessed.
B. Movement of the trachea toward the unaffected side is a sign of a tension pneumothorax, a life-threatening condition requiring immediate medical intervention. This tracheal deviation suggests that the pressure in the pleural space is increasing, pushing the mediastinum to the opposite side.
C. Scant serosanguinous drainage on the dressing is expected and not an immediate concern unless it becomes excessive.
D. Crepitus, or subcutaneous emphysema, indicates air leakage into the tissues but is not immediately life-threatening unless it is extensive and worsening rapidly.
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