Patient Data
After completing the initial assessment, the nurse has reviewed the 0930 laboratory results of blood specimens obtained in the outpatient clinic.
Drag from Word Choices to complete the sentence.
The nurse determines that the findings are reflective of
andThe Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Uremic Encephalopathy: The client has chronic kidney disease and elevated blood urea nitrogen (BUN) levels, indicating impaired kidney function. Symptoms such as feeling tired, fever, and possibly altered mental status can be associated with uremic encephalopathy, a condition that arises from the accumulation of toxins in the blood due to kidney failure.
Fluid Volume Overload: The client has elevated blood pressure (140/86 mm Hg), an irregular and elevated heart rate (117 beats/minute), and respiratory rate (36 breaths/minute), which can be signs of fluid volume overload. Additionally, the slight bibasilar infiltrates observed in the chest X-ray suggest potential fluid accumulation in the lungs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While monitoring urinary output is important, it is not the most critical assessment in this context.
B. Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C. Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D. Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.
Correct Answer is B
Explanation
A. Ensuring that someone stays with the client for 24 hours is important for immediate postoperative care but does not directly ensure compliance with self-care instructions.
B. The teach-back method involves asking the client to repeat in their own words the instructions you just provided. This confirms that they understand the information correctly and are able to follow it at home. For a client with hearing difficulties, this ensures that any miscommunication is identified and corrected before discharge, improving compliance and safety.
C. Speaking clearly and facing the client for lip reading is helpful for communication but does not ensure that the client fully understands and can follow the instructions.
D. Providingwritten instructions for eye drop administrationis useful as a supplement, but written instructions may not guarantee understanding, especially if the client has visual limitations or confusion.
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