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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: Cloudy efluent doesn't necessarily indicate a need for emergency surgery unless accompanied by severe symptoms.

Choice B rationale: Cloudy efluent may indicate infection, so obtaining a culture and sensitivity test is crucial for appropriate treatment.

Choice C rationale: This step might be necessary if the efluent suggests infection, but sending a specimen for testing is the immediate priority.

Choice D rationale: This action isn't the first step; investigating the cause of cloudiness through testing is essential.

A. Provides coverage for possible trichomonas infection. B. Prevent reinfection during treatment. C. Treat any coexisting syphilis infection. D. Provides coverage for possible chlamydia infection.

Correct Answer is D

Explanation

Choice A rationale: The combination treats gonorrhea and chlamydia but not trichomonas.

Choice B rationale: While important, this combination aims to treat multiple potential infections, not solely prevent reinfection.

Choice C rationale: The dual therapy doesn’t cover syphilis; it's specifically targeted for gonorrhea and chlamydia.

Choice D rationale: Azithromycin covers both gonorrhea and chlamydia, so the combination ensures coverage for both possible infections.

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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

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Naxlex Comprehensive Predictor Exams

When providing care for a client receiving peritoneal dialysis. While draining the dialysate the nurse notices that the efluent is cloudy. Which intervention is most important for the nurse to carry out at this moment?

Correct Answer is B

Explanation

A patient with gonorrhea is treated with a single IM dose of ceftriaxone and is given a prescription for azithromycin (Zithromax) 1000 mg 1 dose. What rationale should the nurse provide to the patient for this combination?

Correct Answer is D

Explanation

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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