Try Naxlex NCLEX-RN (Free-Trial)

Exhibits

Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse.

The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with:

Fatigue

Generalized weakness

Muscle cramps

Tingling sensation in her arms and legs

Lightheadedness

She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.

Initial Vital Signs:

Blood Pressure: 146/82 mmHg

Heart Rate: 114 bpm

Respiratory Rate: 18 bpm

SpO₂: 98% on room air

Temperature: 98.2 °F (36.8 °C) orally

Muscle cramps

Tingling sensation in her arms and legs

Lightheadedness

Fatigue

68-year-old with a history of diabetes, hypertension

Blood Pressure: 146/82 mmHg

Heart Rate: 114 bpm

Temperature: 98.2 °F

Answer and Explanation

The Correct Answer is ["A","B","C"]

The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness.

These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma.

The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:
Sweet potatoes are not typically high in oxalates and are generally considered safe to consume in moderation for individuals with calcium oxalate renal stones.

Choice B rationale:
Spinach is high in oxalates, which can contribute to the formation of calcium oxalate renal stones. Therefore, the client should be instructed to avoid spinach and foods high in oxalates.

Choice C rationale:
Bananas are generally low in oxalates and are not likely to be a significant contributor to the formation of calcium oxalate renal stones. They are safe for most individuals to consume.

Choice D rationale:
Fish is generally not high in oxalates and is not a major concern for individuals with calcium oxalate renal stones. However, it's essential to maintain an overall balanced diet and stay hydrated to prevent stone formation.

A. Five-pound (2.3 kg) weight gain. B. Nausea and vomiting. C. Short-term memory loss. D. Depressed affect.

Correct Answer is B

Explanation

Choice A rationale:
A five-pound weight gain in a client taking lithium carbonate is significant. however, the timeframe of the weightgain is to be known.Choice B rationale:
Nausea and vomiting are known side effects of lithium that should be reported as they can cause electrolyte imbalance.

Choice C rationale:
Short-term memory loss is a potential side effect of lithium, but it may not require immediate reporting unless it significantly affects the client's daily functioning or is associated with other concerning symptoms.

Choice D rationale:
A depressed affect is a symptom that should be addressed as part of the client's ongoing psychiatric care, but it may not warrant immediate reporting unless it is severe and requires a change in the treatment plan. The priority in this case is the potential lithium toxicity indicated by the weight gain.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

Correct Answer is B

Explanation

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

Correct Answer is B

Explanation

The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?