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

Answer and Explanation

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.

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Correct Answer is B

Explanation

a. Complete heart block: Complete heart block would typically present with a regular ventricular rate, but with no association between P waves and QRS complexes.

b. Atrial fibrillation: Atrial fibrillation is characterized by the absence of identifiable P waves and an irregular ventricular rate. The atria fibrillate, leading to chaotic electrical activity and an irregular ventricular response.

c. Sinus tachycardia: Sinus tachycardia is characterized by a regular ventricular rate and identifiable P waves. It is not associated with the absence of P waves.

d. First-degree AV block: First-degree AV block is characterized by a prolonged PR interval, but it does not result in the absence of P waves. The relationship between P waves and QRS

complexes is maintained.

A. Instruct the client to tilt her head back when she swallows. B. Add thickener to fluids. C. Place food on the left side of the client's mouth. D. Serve food at room temperature.

Correct Answer is B

Explanation

a. Instruct the client to tilt her head back when she swallows: This action is not recommended, as it increases the risk of aspiration. Tilted head positions can lead to improper bolus control and

swallowing difficulties.

b. Add thickener to fluids: This is an appropriate intervention for a client with dysphagia, as thickened fluids are easier to control during swallowing and reduce the risk of aspiration.

c. Place food on the left side of the client's mouth: This action may not directly address the risk of aspiration associated with dysphagia and left-sided weakness.

d. Serve food at room temperature: While serving food at room temperature may be preferred for some clients, it does not directly address the safety concerns associated with dysphagia and left- sided weakness.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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