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 C
Explanation
A. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.
B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.
The priority is to determine the client's immediate physiological status.
C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of
nausea and refusal of breakfast.
D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.
Correct Answer is A
Explanation
a. Postictal phase: The postictal phase refers to the period following a seizure during which the individual may be drowsy, confused, or sleepy. This phase can last varying amounts of time.
b. Presence of absence seizures: Absence seizures are characterized by brief episodes of staring and altered consciousness but do not typically have a postictal phase with prolonged sleepiness.
c. Aura phase: The aura phase occurs before a seizure and involves sensory or perceptual changes that serve as a warning sign. It does not describe the postictal state.
d. Presence of automatisms: Automatisms are repetitive, non-purposeful movements that can occur during certain types of seizures but do not describe the postictal state of sleepiness.
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