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 A
Explanation
Choice A rationale: Post-surgery, there's a risk of lymphedema in the affected arm, so avoiding procedures like venipuncture or blood pressure measurements in the left arm helps prevent complications.
Choice B rationale: Obtaining a permanent breast prosthesis is a consideration post- recovery but not an immediate priority upon return to the surgical unit.
Choice C rationale: Patient-controlled analgesia instructions are important but don't specifically address immediate care after mastectomy.
Choice D rationale: Insisting that the patient examine the surgical incision might not be appropriate upon return to the unit, and it's typically done by healthcare professionals during dressing changes.
Correct Answer is B
Explanation
Choice A rationale: Elevated T3 and T4 with low TSH levels are indicative of hyperthyroidism, not a side effect of radioactive iodine treatment.
Choice B rationale: One of the expected side effects of RAI treatment for hyperthyroidism is permanent hypothyroidism (or underactive thyroid, when the thyroid does not produce enough hormones). Elevated TSH levels with low T3 and T4 are indicative of hypothyroidism.
Choice C rationale: Low TSH, T3, and T4 levels are not typical outcomes of radioactive iodine treatment; typically, the treatment leads to a decrease in T3 and T4 with increased TSH levels.
Choice D rationale: Elevated TSH and low T3 is major side effect of radioactive iodine treatment for hyperthyroidism. However, it does not cause elevated T4 levels.
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