A nurse is caring for a client who has chronic kidney failure. The client received hemodialysis 1 hr ago. The nurse should identify that which of the following findings is a manifestation of a complication related to the procedure?
A palpable thrill at the fistula site
Hyperglycemia
Altered mental status
Decrease in weight
The Correct Answer is C
A. A palpable thrill at the fistula site: A palpable thrill is a normal finding that indicates proper blood flow through the arteriovenous fistula. The absence of a thrill would be concerning, as it may suggest clotting or dysfunction of the vascular access.
B. Hyperglycemia: Hemodialysis does not typically cause hyperglycemia. Clients with diabetes may experience fluctuations in blood glucose levels, but dialysis itself is more commonly associated with hypoglycemia due to the removal of glucose from the bloodstream.
C. Altered mental status: Neurological changes such as confusion, restlessness, or decreased responsiveness may indicate dialysis disequilibrium syndrome (DDS). This complication results from rapid fluid and solute shifts, leading to cerebral edema. It is a serious condition requiring immediate intervention.
D. Decrease in weight: A decrease in weight following hemodialysis is expected due to fluid removal. Clients are weighed before and after dialysis to monitor fluid balance, and weight loss after treatment indicates effective fluid removal rather than a complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Flushed cheeks: Tuberculosis typically presents with systemic symptoms such as fever, night sweats, and weight loss rather than flushed cheeks. Flushing is more commonly associated with fever spikes in other infections or conditions like menopause.
B. Severe headaches: Tuberculosis can cause headaches if it leads to tuberculous meningitis, but this is not a common initial symptom of pulmonary tuberculosis. Headaches are not a hallmark feature of active TB infection.
C. Low-grade fever: A persistent low-grade fever, particularly in the afternoon or evening, is a common symptom of tuberculosis. It is often accompanied by night sweats and weight loss due to the chronic inflammatory response.
D. Dry cough: The cough associated with tuberculosis is usually productive with purulent or blood-tinged sputum rather than dry. The infection causes lung tissue destruction, leading to a persistent cough with mucus production.
Correct Answer is A
Explanation
A. Xerostomia: Radiation therapy to the head and neck often damages the salivary glands, leading to xerostomia, or dry mouth. This can cause difficulty in speaking, swallowing, and an increased risk of oral infections. Providing oral hydration and saliva substitutes can help manage this side effect.
B. Epistaxis: While radiation therapy can cause mucosal irritation, epistaxis (nosebleeds) is not a common side effect. Epistaxis is more frequently associated with conditions such as nasal trauma, clotting disorders, or chemotherapy-induced thrombocytopenia rather than localized radiation therapy.
C. Tinnitus: Radiation therapy does not typically cause tinnitus, which is more commonly linked to ototoxic medications, prolonged noise exposure, or inner ear disorders. If a tumor or treatment affects the auditory structures, hearing-related symptoms may occur but are not a primary radiation side effect.
D. Diplopia: Double vision is not a usual complication of radiation therapy to the head and neck. Diplopia is more commonly associated with neurological conditions, cranial nerve dysfunction, or ocular disorders rather than radiation-induced effects on surrounding tissues.
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