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 B
Explanation
A. Graham crackers: Hard, crunchy foods can trigger pain by irritating the trigeminal nerve, making them unsuitable for clients with trigeminal neuralgia. Soft, easy-to-swallow foods are preferred.
B. Vanilla pudding: Soft, smooth-textured foods are recommended to minimize irritation of the trigeminal nerve. Vanilla pudding requires minimal chewing, reducing the risk of triggering pain.
C. Ice cream: Extremely cold foods can act as a trigeminal nerve irritant and may provoke pain episodes. Lukewarm or room-temperature foods are preferable.
D. Vegetable soup: Although liquid-based, vegetable soup often contains solid pieces that require chewing, which can increase the risk of triggering pain. Blended or pureed soups are a better option.
Correct Answer is B
Explanation
A. Increase in urinary output: Mannitol is an osmotic diuretic that promotes diuresis to reduce intracranial pressure (ICP). Increased urinary output is an expected effect and indicates the medication is working as intended.
B. Crackles on auscultation: Mannitol can lead to fluid overload, especially in clients with compromised renal or cardiac function. Crackles in the lungs suggest pulmonary edema, a serious adverse effect that should be reported immediately to prevent respiratory distress.
C. Intracranial pressure reading of 12 mm Hg: Normal ICP ranges from 5 to 15 mm Hg. A reading of 12 mm Hg is within the expected range and does not indicate an adverse effect of mannitol.
D. Glasgow coma scale rating of 15: A score of 15 indicates full consciousness and normal neurological function. This finding does not suggest an adverse reaction to mannitol.
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