A nurse is receiving report on four clients. Which of the following clients should the nurse assess first?

A client who has an ileal conduit and mucus in the pouch

A client who has an arteriovenous fistula that vibrates when palpated

A client who had a transurethral resection of the prostate with red-tinged urine in the bag

A client who has chronic kidney disease with cloudy dialysate outflow

Answer and Explanation

The Correct Answer is C

A. A client who has an ileal conduit and mucus in the pouch - While mucus in the ileal conduit pouch should be monitored, it is not an urgent priority compared to assessing for potential complications such as bleeding in another client.

B. A client who has an arteriovenous fistula that vibrates when palpated - A vibrating arteriovenous fistula indicates normal functioning and does not require immediate assessment.

C. A client who had a transurethral resection of the prostate with red-tinged urine in the bag - Red-tinged urine may indicate bleeding, a potential complication after a transurethral resection of the prostate, requiring prompt assessment and intervention.

D. A client who has chronic kidney disease with cloudy dialysate outflow - While cloudy dialysate outflow may indicate infection or other complications in a client with chronic kidney disease on peritoneal dialysis, it is not as urgent as assessing for bleeding in the client with red- tinged urine.

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Correct Answer is C

Explanation

A. Encouraging the client to gain 2.3 kg (5 lb) per week may be excessive and unrealistic, potentially contributing to feelings of failure and exacerbating the client's condition.

B. Weighing the client once per week throughout hospitalization is important for monitoring weight changes, but it does not specifically address the immediate post-meal monitoring needed to prevent complications such as purging.

C. Monitoring the client for 1 hr after meals helps prevent behaviors such as purging or other forms of compensatory behaviors that may occur immediately after eating.

D. Allowing the client to choose meal times may not be appropriate as it can perpetuate disordered eating patterns. Establishing regular meal times is important for promoting consistent eating habits.

A. Decreased reflexes B. Weight gain of 1.4 kg (3 lb) C. Increased urinary output D. Jugular vein distention E. None F. None

Correct Answer is A

Explanation

A. Decreased reflexes can indicate electrolyte imbalance, particularly hypokalemia, which is a common adverse effect of loop diuretics. Low potassium levels can affect neuromuscular function and should be reported and addressed promptly.

B. A weight gain of 1.4 kg (3 lb) suggests fluid retention and worsening heart failure, not an adverse effect of the diuretic. Loop diuretics are expected to promote weight loss through fluid removal.

C. Increased urinary output is an expected therapeutic effect of a loop diuretic and indicates the medication is working as intended.

D. Jugular vein distention reflects fluid volume overload associated with heart failure rather than an adverse medication effect.

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