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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: This does not match the peak time of NPH insulin.
Choice B rationale: This does not match the peak time of NPH insulin.
Choice C rationale: This does not match the peak time of NPH insulin.
Choice D rationale: This is because NPH insulin is an intermediate-acting insulin that has an onset of action of 1 to 2 hours, a peak of 6 to 12 hours, and a duration of 18 to 24 hours. Therefore, if Albert is given NPH insulin at 0730, the peak effect will occur between 1330 and 1930, which means that his blood glucose level will be lowest during this time.

A. A 6 year old that is presenting with polyuria, polydipsia, abdominal pain, and vomiting B. A 66 year old with type I diabetes that has ketones present in their urine. C. A 72 year old with a health history of diabetes who has a blood glucose of 300 mg/dL and is complaining of thirst and frequent urination. D. A 69 year old admitted with an infection of the right foot with a health history of diabetes that reports missing several doses of Metformin and has a blood glucose of 600 mg/dL.

Correct Answer is D

Explanation

Choice A rationale: This may indicate a different condition such as gastroenteritis rather than Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS).

Choice B rationale: This is more indicative of diabetic ketoacidosis (DKA) rather than HHNS.

Choice C rationale: A 72-year-old with a history of diabetes, elevated blood glucose, and complaints of thirst and frequent urination might have uncontrolled diabetes, but the absence of severe hyperglycemia and other symptoms specific to HHNS makes this choice less likely.

Choice D rationale: This fits the criteria for HHNS. The infection, missed medication, and extremely high blood glucose levels suggest the possibility of Hyperglycemic Hyperosmolar Nonketotic Syndrome.

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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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Correct Answer is B

Explanation

Which of the following patients is most likely experiencing Hyperglycemic Hyperosmolar Nonketotic Syndrome based on their symptoms?

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