A nurse is collecting data from a client who has pernicious anemia.
The nurse should identify that which of the following findings increases the client's risk for injury?

The correct answer is Choice D: Obtain the client's weight.

Choice D rationale: Obtaining the client's weight is crucial in planning hemodialysis treatment, as it helps determine the amount of fluid that needs to be removed during the procedure. This information contributes to accurate calculation of the ultrafiltration rate, ensuring adequate fluid balance and preventing potential complications associated with fluid overload or excessive fluid removal.

Choice A rationale: Encouraging the client to increase fluid intake is not recommended in the context of hemodialysis, as excessive fluid intake may result in fluid overload, a common complication in patients undergoing this treatment. Instead, the nurse should advise the client on appropriate fluid restrictions, taking into account their individualized plan of care.

Choice B rationale: Reinforcing the practice of sleeping on the side of the access site is not advisable because it could lead to increased pressure on the arteriovenous fistula, potentially causing complications such as thrombosis or stenosis. It is generally recommended that clients avoid putting pressure on the access site, particularly during sleep or when engaging in activities that could cause direct contact with the area.

Choice C rationale: Obtaining the client's blood pressure in either arm is not the appropriate approach, as the arm with the arteriovenous fistula should not be used for blood pressure measurements or any other procedures that could damage the fistula. Blood pressure should be measured in the non-access arm to ensure the integrity of the vascular access and minimize the risk of complications.

The correct answer is Choice D.

Choice A rationale: Documenting the event in the client’s progress notes is not the most appropriate action in this situation. The client’s progress notes should contain information about the client’s health status and care, not about staff behavior. Furthermore, documenting this incident in the client’s notes could potentially violate the client’s privacy if the notes are accessed by individuals who do not need to know about the incident.

Choice B rationale: Submitting an incident report to the risk manager is not the most appropriate action in this situation. Incident reports are typically used for events that have caused or have the potential to cause harm to a client, such as medication errors or falls. In this case, while the APs’ behavior is inappropriate, it has not caused harm to the client.

Choice C rationale: Informing the client of the APs’ actions is not the most appropriate action in this situation. Doing so could unnecessarily worry or upset the client. The nurse’s role is to advocate for the client and protect their privacy and dignity, which includes not sharing information about inappropriate staff behavior with the client.

Choice D rationale: Telling the APs to stop the conversation is the most appropriate action in this situation. The nurse has a professional responsibility to address inappropriate behavior by other healthcare team members. Discussing a client in a public area, such as the nurses’ station, is a breach of client confidentiality. The nurse should remind the APs of the importance of maintaining client confidentiality and direct them to stop the conversation.