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 B
Explanation
Choice A rationale: These side effects are not related to spironolactone use.
Choice B rationale: These are common side effects of spironolactone, as it causes potassium retention and sodium loss.
Choice C rationale: These side effects are not related to spironolactone use.
Choice D rationale: These side effects are not related to spironolactone use.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
Choice A rationale: The lab results and clinical picture, such as weight loss, anorexia, and high blood glucose levels, point more toward a hyperglycemic state rather than severe hypoglycemia.
Choice B rationale: The client's elevated blood glucose levels, weight loss, and anorexia suggest a hyperglycemic state, possibly hyperosmolar hyperglycemic state, which requires fluid management and insulin to address the severe dehydration and high blood glucose levels.
Choice C rationale: Although high glucose levels are evident, the absence of significant acidosis (as seen in diabetic ketoacidosis) and extreme ketosis makes this diagnosis less likely.
Choice D rationale: The lab values and clinical presentation do not strongly align with a primary respiratory acidosis diagnosis, which typically involves changes in pH and carbon dioxide levels.
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