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 C
Explanation
A. "Most people in your situation are able to get through this.": This statement is dismissive and may minimize the client’s feelings, as it generalizes the experience.
B. "Why do you think you're feeling so alone?": Asking "why" may make the client feel defensive and pressured to justify their feelings, which is not therapeutic.
C. "Do you have anyone you can talk to about your diagnosis?" This response encourages the client to reflect on their support system, which may help reduce feelings of isolation. It also shows empathy and invites further conversation without making assumptions.
D. "I am so sorry about your diagnosis. You must be devastated.": While it shows sympathy, it assumes the client’s feelings and may inadvertently heighten the client’s sense of distress without providing support.
Correct Answer is C
Explanation
A. 20: Incorrect, as it would imply a much higher dose.
B. 0.2: Incorrect, as this would be far too low.
C. 2: Phenytoin 0.2 g is equivalent to 200 mg (0.2 g x 1000 mg/g). Since each capsule is 100 mg, the nurse would need to administer 2 capsules (200 mg / 100 mg per capsule = 2).
D. 200: Incorrect, as 200 capsules would be an overdose.