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The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/98 mm Hg, pulse 66 beats/min, and temperature is 98°F (37.6°C). What is the most appropriate action by the nurse?
- A. Administer fluid to increase blood pressure
- B. Monitor the client closely for hypotension
- C. Assess for signs of infection
- D. Continue routine monitoring
Correct Answer: B
Rationale: The blood pressure of 110/98 mm Hg is relatively low post-hemodialysis and could indicate hypotension, a common complication. The most appropriate action is to monitor the client closely for signs of hypotension, such as dizziness or weakness, to ensure stability.
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A client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Which nurse should be assigned to this client for continuity of care?
- A. A new graduate nurse
- B. A float nurse from another unit
- C. The registered nurse (RN) previously assigned to this client
- D. A licensed practical nurse (LPN)
Correct Answer: C
Rationale: Continuity of care is important to assess subtle differences in clients. Therefore, the registered nurse (RN) who was assigned to this client previously should again give care to this client. The first nurses would not be as knowledgeable about the unit and its clients. The licensed practical nurse may not have the education level of the RN to assess for pericarditis.
A client is taking furosemide (Lasix) for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best?
- A. Assess the client's vital signs
- B. Auscultate heart and breath sounds
- C. Replace the client's abdomen
- D. Assess the client's diet history
Correct Answer: A
Rationale: Furosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds should be assessed if there is fluid retention. The best initial action is to assess vital signs, including weight, to evaluate fluid status.
A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?
- A. Warm the dialysis solution in a microwave before instillation
- B. Take a sample of the effluent and send to the laboratory
- C. Flush the tubing with normal saline to maintain patency of the catheter
- D. Check the catheter for obstruction
Correct Answer: B
Rationale: An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse.
A client in the intensive care unit is started on continuous venous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse?
- A. Blood leak detector alarm
- B. Low ultrafiltrate volume
- C. High venous pressure
- D. Low arterial pressure
Correct Answer: A
Rationale: A blood leak detector alarm indicates a potential rupture in the dialysis membrane, which is a critical issue requiring immediate action to stop the procedure and ensure patient safety. Low ultrafiltrate volume, high venous pressure, or low arterial pressure may require adjustments but are not as immediately life-threatening.
A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 100/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply)
- A. Adjust the rate of extracorporeal blood flow
- B. Place the client in the Trendelenburg position
- C. Administer oxygen therapy
- D. Administer a 250-mL bolus of normal saline
- E. Contact the health care provider for orders
Correct Answer: A,B,D
Rationale: Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Adjusting the extracorporeal blood flow, placing the client in the Trendelenburg position, and administering a normal saline bolus can help stabilize blood pressure.