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 D
Explanation
Choice A rationale: This is not relevant to the current condition of the patient and does not support a diagnosis of renal calculi.
Choice B rationale: This is a sign of upper gastrointestinal bleeding, which can have many causes such as peptic ulcer, gastritis or esophageal varices. It is not related to renal calculi or urinary tract problems.
Choice C rationale: Renal calculi usually causes pain which usually radiates anteriorly to the lower abdomen, groin, labia, testicles or the perineum depending on the location of the stone.
Choice D rationale: This is a sign of hematuria, which is blood in the urine caused by the passage of renal calculi (kidney stones) through the urinary tract. Hematuria can also cause the urine to appear dark or brown in color.
Correct Answer is A
Explanation
Choice A rationale: This is because removing a large amount of fluid from the abdominal cavity can cause a sudden decrease in intra-abdominal pressure, which can lead to hypovolemia and hypotension. The body compensates by increasing the heart rate to maintain cardiac output and perfusion.
Choice B rationale: This is not directly related to paracentesis and may indicate other conditions.
Choice C rationale: This is not directly related to paracentesis and may indicate other conditions.
Choice D rationale: This is not directly related to paracentesis and may indicate other conditions.
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