A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available for use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement?
Serum Albumin Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)
Recommend the use of support stockings to enhance venous return
Ensure the client receives frequent small meals containing complete proteins
Evaluate patency of the AV graft for resumption of hemodialysis
Instruct the client to continue to follow the prescribed rigid fluid restriction amounts
The Correct Answer is B
Choice A reason: Support stockings may help with peripheral edema, but they are not the priority intervention for this client. The client's low serum albumin level indicates malnutrition and increased risk of infection and poor wound healing.
Choice B reason: This is the correct answer because the client needs adequate protein intake to maintain serum albumin levels and prevent further complications. Complete proteins contain all nine essential amino acids that the body cannot synthesize and are found in animal sources such as meat, eggs, and dairy products.
Choice C reason: Evaluating patency of the AV graft is not the priority intervention for this client because the client is receiving peritoneal dialysis, not hemodialysis. The AV graft may be used in the future if peritoneal dialysis fails, but it is not an immediate concern.
Choice D reason: Instructing the client to follow fluid restriction amounts is important for peritoneal dialysis patients, but it is not the priority intervention for this client. The client's low serum albumin level indicates that fluid restriction alone is not sufficient to manage fluid balance and prevent edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Yellow-tinged sputum is not a serious adverse effect of linezolid. It may indicate an infection or inflammation in the respiratory tract, but it does not require immediate attention from the health care provider.
Choice B reason: Nausea and headache are common side effects of linezolid. They are usually mild and self-limiting, and they can be managed with supportive measures such as hydration, rest, and analgesics.
Choice C reason: Watery diarrhea is a sign of pseudomembranous colitis, a potentially life-threatening complication of linezolid. It is caused by an overgrowth of Clostridium difficile bacteria in the colon, which produce toxins that damage the intestinal mucosa. It can lead to dehydration, electrolyte imbalance, sepsis, and perforation. The nurse should report this finding to the health care provider immediately and stop the linezolid infusion.
Choice D reason: Increased fatigue is not a specific or serious adverse effect of linezolid. It may be related to the underlying infection, anemia, or other factors. It does not require urgent intervention from the health care provider.
Correct Answer is B
Explanation
Choice A reason: Determining the need for urinary catheterization is not a task that the nurse should assign to the PN, as this requires clinical judgment and critical thinking, which are beyond the scope of practice of the PN. This is a distractor choice.
Choice B reason: Titrating oxygen to prescribed parameters is a task that the nurse can assign to the PN, as this involves following orders and protocols, which are within the scope of practice of the PN. Therefore, this is the correct choice.
Choice C reason: Receiving a postoperative client and conducting the assessment is not a task that the nurse should assign to the PN, as this requires initial assessment and data collection, which are the responsibility of the registered nurse. This is another distractor choice.
Choice D reason: Evaluating and updating plans of care for clients is not a task that the nurse should assign to the PN, as this requires nursing diagnosis and outcome identification, which are part of the nursing process that only the registered nurse can perform. This is another distractor choice.
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