A nurse is collecting data from a client who has diabetic ketoacidosis.
Which of the following findings should the nurse expect?

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.

Choice A rationale:

Soft bowel sounds at a rate of 1 per minute describe hypoactive bowel sounds, which indicate decreased motility. This choice does not describe hyperactive bowel sounds.

Choice B rationale:

High-pitched bowel sounds are characteristic of hyperactive bowel sounds. These sounds are associated with increased motility and can indicate conditions such as diarrhea or early bowel obstruction. This choice correctly describes hyperactive bowel sounds.

Choice C rationale:

The absence of bowel sounds after listening for 3 to 5 minutes is indicative of absent or hypoactive bowel sounds, not hyperactive bowel sounds.