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. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.
B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.
C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.
D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.
Correct Answer is C
Explanation
A. The client is terminally ill: DPOA is not automatically activated by terminal illness but by the client’s inability to communicate.
B. The client is incapable of providing self-care: This alone does not activate the DPOA unless they are also unable to make healthcare decisions.
C. The client is unable to express their wishes: Durable power of attorney for healthcare decisions is activated when the client becomes unable to make or communicate their healthcare choices.
D. The client has refused treatment: Refusal of treatment is a decision that an alert and capable client can make independently.