The nurse is caring for a 67-year-old client in the medical-surgical unit following hemodialysis.
The nurse reviews the nursing note, vital signs, assessment, and medical history
Which clinical data is most concerning to the nurse? Select all that apply
A/V fistula assessment
Blood pressure
Pulse
Anuria
Oxygen saturation
Temperature
Neurological assessment
Correct Answer : B,C,D,E
Choice A rationale: A/V fistula assessment is not concerning because a positive bruit and thrill indicate adequate blood flow through the fistula. A dry dressing with scant amount of blood is expected after hemodialysis.
Choice B rationale: The client's low blood pressure could indicate hypotension, which can be critical, especially after hemodialysis. It may contribute to the client's reported dizziness and fatigue.
Choice C rationale: The client’s pulse is irregular which may indicate cardiac arrhythmia. Choice D rationale: Anuria, the absence of urine output, is a significant concern. It could indicate kidney dysfunction or inadequate clearance of waste products, which may have implications following hemodialysis.
Choice E rationale: Oxygen saturation at 92% is relatively low. While the client is alert and oriented, a low oxygen saturation level may indicate potential respiratory compromise or inadequate oxygenation.
Choice F rationale: Temperature is not concerning because it is within normal range.
Choice G rationale: Neurological assessment is not concerning because the client is alert and oriented. The dizziness is likely related to the hypotension and will resolve once the blood pressure is stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: This statement is correct; it's important to include the final voided urine in the collection.
Choice B rationale: Proper storage at a cool temperature helps maintain the integrity of the collected urine.
Choice C rationale: Avoiding protein intake during the collection can significantly alter the results of the creatinine clearance test. Eating a regular diet is important to maintain accurate test results.
Choice D rationale: Discarding the first void and starting the collection afterward is a common practice in 24-hour urine collections to ensure a complete sample.
Correct Answer is B
Explanation
Choice A rationale: Cerebral motor cortex primarily controls voluntary movements, not autonomic functions like respiration, heart rate, and blood pressure.
Choice B rationale: The brain stem controls vital functions like respiration, heart rate, and blood pressure, so damage to this area can lead to difficulties in these functions.
Choice C rationale: Broca's area is responsible for speech production and is not directly involved in autonomic functions.
Choice D rationale: The occipital lobe is primarily associated with visual processing and perception, not autonomic functions like respiration or heart rate.
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