A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses?
Neck vein distention
Body weight
Abdominal girth
Blood pressure
The Correct Answer is B
a. Neck vein distention: Neck vein distention may indicate fluid overload, but it is not a direct measure of fluid losses.
b. Body weight: Monitoring body weight before and after hemodialysis provides a direct
measure of fluid losses. Hemodialysis removes excess fluid, and changes in body weight reflect fluid balance.
c. Abdominal girth: Abdominal girth may be affected by fluid accumulation but is not a direct measure of fluid losses during hemodialysis.
d. Blood pressure: While blood pressure may be influenced by fluid status, it is not a specific measure of fluid losses during hemodialysis. Body weight is a more direct indicator of fluid removal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.
b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.
c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.
d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.
Correct Answer is C
Explanation
a. Slow: Atrial fibrillation is characterized by an irregular heart rate, but it may not necessarily be slow. The rate can vary, and it is irregularly irregular.
b. Not palpable: While atrial fibrillation can result in an irregularly irregular pulse, it is not necessarily indicative of a pulse that is not palpable.
c. Irregular: Atrial fibrillation is associated with an irregularly irregular pulse due to the chaotic and disorganized atrial activity.
d. Bounding: Bounding pulses are characterized by a forceful and strong pulse, which is not typically associated with atrial fibrillation.
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