The nurse prepares the client for HD. Which assessments should the nurse complete before initiating HD? (Select all that apply.)
1. Check mental status.
2. Obtain client weight.
3. Evaluate heart rhythm.
4. Palpate peripheral pulses.
5. Measure abdominal girth.
6. Palpate bruit of AV fistula.
1, 2, 3, 4
1. To establish baseline data, the nurse completes client assessment before initiating HD. The nurse checks the client mental status because a change in mentation can re-flect a fluid and electrolyte imbalance.
2. The nurse obtains the client weight before dialysis to determine how much fluid was drawn off by HD.
3. The nurse checks the client's heart rhythm because electrolyte imbalances are often assessed by an irregular heart rhythm.
4. The nurse evaluates peripheral circulation of all extremities to complete a client assessment.
5. Abdominal girth can be valuable baseline data before infusing dialysate during PD.
6. The nurse auscultates the bruit of a graft and palpates the thrill of an AV fistula.
You might also like to view...
The nurse is planning a teaching session with the client who is about to be discharged. Which of the following, if planned by the nurse, would enhance the client learning experience? Select all that apply. Standard Text: Select all that apply
1. The nurse plans to ask the client to select the time of the session. 2. The nurse plans to show the client a videotape while the client rests in bed. 3. The nurse plans to advise the client to use the supplies from the hospital. 4. The nurse plans to review the material at the end of the session. 5. The nurse plans on using appropriate medical terminology.
To ensure accuracy of measurements, the nurse performs vital signs assessment in which order?
a. Respiration, temperature, pulse b. Pulse, respiration, temperature c. Temperature, pulse, respiration d. Respiration, pulse, temperature
A client has to undergo a variation of gastrointestinal endoscopy called esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. What should the nurse observe for while assessing the client during the procedure?
A) Signs of perforation B) The client's level for retaining the barium C) The client's tolerance for pain and discomfort D) Gag reflex
When you palpate a 5-year-old's neck, you identify small, movable, cool, nontender lymph nodes. Your findings would most likely indicate which of the following?
a. benign "shotty" nodes with no clinical significance b. malignant and require further assessment immediately c. related to lymphadenitis d. related to an acute upper respiratory infection