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 refers to postrenal AKI, which is caused by an obstruction in the urinary tract that prevents urine from leaving the body.
Choice B rationale: This refers to AKI in general and is not specific compared to choice D.
Choice C rationale: This refers to intrinsic AKI, which is caused by damage to the kidney tissue or cells from various causes, such as inflammation, infection, toxins, or ischemia.
Choice D rationale: This is correct because it is pre-renal AKI, a condition in which kidney blood flow may become significantly reduced, including cases where a significant amount of fluid has been lost. This situation suggests potential hypovolemia (low blood volume) due to the massive GI bleed, which can lead to reduced kidney blood flow and subsequent acute kidney injury.
Correct Answer is B
Explanation
Choice A rationale: This is not accurate since the manifestations of facial nerve paralysis are observed on the contralateral side which in this case is the left side of the face hence the right facial nerve is paralyzed.
Choice B rationale: Facial nerve paralysis cause symptoms such as drooping of the eyelid, cheek or mouth as depicted in the above picture. The right facial nerve is paralyzed since the nerve innervates the contralateral side hence the effects are demonstrated on the
left side of the face.
Choice C rationale: trigeminal nerve paralysis causes symptoms such as weakness in muscles of mastication, altered sensation over the face and tongue, and hearing impairment and not the symptoms depicted above.
Choice D rationale: trigeminal nerve paralysis causes symptoms such as weakness in muscles of mastication, altered sensation over the face and tongue, and hearing impairment and not the symptoms depicted above.
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