The nurse in the dialysis unit is initiating the morning scheduled dialysis clients. Which client would the nurse prioritize to assess first?
The client on peritoneal dialysis who is reporting a hard and rigid abdomen.
The client who does not have a palpable thrill or auscultated bruit.
The client who is reporting a 3.6 kg weight gain and it refusing dialysis.
The client who has a hemoglobin of 9.0 mg/dL (12.0-15.5 mg/dL) and hematocrit of 26% (36.1% -44.3%).
The Correct Answer is A
A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. A hard, rigid abdomen suggests peritonitis, a life-threatening complication requiring immediate assessment and intervention.
B. The client who does not have a palpable thrill or auscultated bruit: This indicates a possible vascular access issue, but it is not as immediately life-threatening as peritonitis.
C. The client who is reporting a 3.6 kg weight gain and refusing dialysis: This weight gain could signal fluid overload, but refusal of dialysis would require a different approach that may not need immediate intervention unless symptoms worsen.
D. The client with a hemoglobin of 9.0 mg/dL and hematocrit of 26%: This low hemoglobin and hematocrit level may require treatment, but it is not an immediate life-threatening issue like peritonitis.
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Correct Answer is ["A","C","D"]
Explanation
A. The client has legal authority to do so: The nurse’s signature confirms that the client appears to have the legal capacity to consent.
B. The client does not have a mental health condition: This is not within the nurse’s purview to assess unless explicitly stated; mental capacity, not condition, is key.
C. The client was not coerced: The nurse’s signature also indicates the consent was given voluntarily, without coercion.
D. The client signed in the nurse's presence: The nurse’s signature confirms that the nurse witnessed the client’s signature.
E. The client speaks the same language as the nurse: Consent requires understanding, which can be provided through an interpreter, so this is not necessary.
Correct Answer is ["A","E","F"]
Explanation
A. Ensure comfortable seating at eye level for the client and nurse: Establishes a non-intimidating environment, helping the client feel more at ease.
B. Provide seating for the client so that the client faces a strong light: Incorrect; this may cause discomfort and make the client feel scrutinized.
C. Ensure that the distance between the client and nurse is at least 7 ft: Too great a distance for effective communication; ideal distance is 3-4 feet.
D. Place a chair for the client across from the nurse's desk: Creates a formal, potentially intimidating setting, discouraging openness.
E. Set the room temperature at a comfortable level: Ensures physical comfort, aiding in client relaxation and openness.
F. Remove distracting objects from the interviewing area: Minimizes potential distractions, keeping the client focused and the environment conducive to communication.