The nurse cares for a client with diabetes mellitus and congestive heart failure.

Exhibits

Which two (2) client findings in the history and physical are most concerning? Select all that apply

Choice A rationale: Kayexalate is not primarily used for phosphate reduction.

Choice B rationale: Kayexalate can have sorbitol in its formulation, which might cause diarrhea rather than constipation.

Choice C rationale: Kayexalate works as a cation-exchange resin that promotes potassium excretion in the bowels.

Choice D rationale: Kayexalate does not add potassium; it exchanges sodium for potassium in the bowels.

Choice A rationale: A/V fistula assessment is not concerning because a positive bruit and thrill indicate adequate blood flow through the fistula. A dry dressing with scant amount of blood is expected after hemodialysis.

Choice B rationale: The client's low blood pressure could indicate hypotension, which can be critical, especially after hemodialysis. It may contribute to the client's reported dizziness and fatigue.

Choice C rationale: The client’s pulse is irregular which may indicate cardiac arrhythmia. Choice D rationale: Anuria, the absence of urine output, is a significant concern. It could indicate kidney dysfunction or inadequate clearance of waste products, which may have implications following hemodialysis.

Choice E rationale: Oxygen saturation at 92% is relatively low. While the client is alert and oriented, a low oxygen saturation level may indicate potential respiratory compromise or inadequate oxygenation.

Choice F rationale: Temperature is not concerning because it is within normal range.

Choice G rationale: Neurological assessment is not concerning because the client is alert and oriented. The dizziness is likely related to the hypotension and will resolve once the blood pressure is stabilized.