A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records.

Exhibits


Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

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.

A. A decreased level of consciousness is a common symptom of ARF due to hypoxemia, which reduces oxygen delivery to the brain, leading to confusion, agitation, or lethargy.

B. Hypercarbia, or elevated levels of carbon dioxide (CO2) in the blood, occurs due to impaired gas exchange in ARF, which leads to respiratory acidosis.

C. Severe dyspnea, or difficulty breathing, is a hallmark symptom of ARF as the lungs fail to maintain adequate oxygenation or ventilation.

D. Nausea is not a typical manifestation of ARF; while it may occur due to other factors, it is not directly associated with respiratory failure.

E. Tachycardia, or an increased heart rate, is often seen in ARF as the body attempts to compensate for hypoxemia by increasing cardiac output to deliver more oxygen to tissues.