The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment the nurse notes that the client’s temperature is 100.2. Which of the following is the most appropriate nursing action?
A. Encourage fluids.
B. Notify the physician.
C. Monitor the site of the shunt for infection.
D. Continue to monitor vital signs.
Correct Answer: D. Continue to monitor vital signs.
The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected, and a blood sample would be obtained as prescribed for culture and sensitivity purposes.
Option A: Avoid contamination of the access site. Use aseptic technique and masks when giving shunt care, applying or changing dressings, and when starting or completing the dialysis process. Prevents the introduction of organisms that can cause infection.
Option B: Notify physician and/or initiate declotting procedure if there is evidence of loss of shunt patency. Rapid intervention may save access; however, declotting must be done by experienced personnel.
Option C: Assess skin around vascular access, noting redness, swelling, local warmth, exudate, tenderness. Signs of local infection, which can progress to sepsis if untreated. Monitor temperature. Note presence of fever, chills, hypotension. Signs of infection or sepsis requiring prompt medical intervention.
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