A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care?

Rationale for correct choices:

• Hemoglobin 12 g/dL: The increase from 9.1 g/dL to 12 g/dL indicates that the client’s anemia is resolving. This suggests effective treatment or stabilization following blood loss, improving oxygen-carrying capacity and overall perfusion.
• Hematocrit 36%: The rise from 27% to 36% reflects an improvement in the proportion of red blood cells in circulation. This correlates with better tissue oxygenation and a positive response to interventions such as a blood transfusion.
• Blood pressure 112/74 mm Hg: The increase from 90/50 mm Hg indicates improved hemodynamic stability. This suggests the client is no longer hypovolemic and is better able to maintain adequate perfusion to vital organs.
• Heart rate 95/min: The decrease from 118/min shows a reduction in compensatory tachycardia. This reflects improved circulatory status and decreased physiological stress following stabilization of blood volume and oxygenation.

Rationale for incorrect choices:

• WBC count 6,700/mm³: The WBC count remains unchanged from admission. While within normal limits, it does not specifically indicate improvement in anemia or hemodynamic status, which are the primary concerns in this scenario.
• Respiratory rate 18/min: The respiratory rate is unchanged and within normal limits. Although stable, it does not provide a direct measure of improvement in anemia or perfusion.
• Temperature 37.5°C (99.5°F): The temperature is stable but slightly elevated. While not concerning, it does not reflect a specific improvement in the client’s primary condition.

Rationale:

A. Acrocyanosis: This is a bluish discoloration of the hands and feet that is common in newborns during the first 24 to 48 hours after birth due to immature circulation. It is not a sign of sepsis.

B. Hypertension: Newborns with sepsis are more likely to present with hypotension due to systemic infection and poor perfusion. Hypertension is not typically associated with neonatal sepsis.

C. Rust-stained urine: This discoloration can occur in newborns from urate crystals in the first few days of life and is considered a normal finding, not an indicator of infection.

D. Retractions: Retractions indicate increased work of breathing and respiratory distress, which can occur in newborn sepsis due to systemic infection affecting respiratory function. This is a concerning finding that warrants prompt evaluation.