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 D
Explanation
A. Flat: A flat abdomen is level with no visible protrusions or concavities.
B. Protuberant: A protuberant abdomen appears swollen or distended, common in obesity or ascites.
C. Rounded: A rounded abdomen has a convex contour, commonly seen in children or adults with mild weight gain.
D. Scaphoid: A scaphoid abdomen appears sunken or concave, often showing visible lower ribs, suggesting malnutrition or dehydration.
Correct Answer is A
Explanation
A. Postural hypotension: Postural hypotension (a drop-in blood pressure when moving to a standing position) is a common sign of extracellular fluid volume deficit due to decreased circulating blood volume.
B. Dependent edema: This occurs with fluid volume excess, not deficit, due to fluid accumulation in tissues.
C. Bradycardia: Fluid volume deficit often leads to tachycardia as the body compensates for low blood volume, rather than a slow heart rate.
D. Distended neck veins: Distended neck veins suggest fluid overload, not a fluid deficit.