Questions 34

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Extract:

The following scenario applies to the next 1 items
The medical-surgical nurse is caring for a 67-year-old client
Item 1 of 1
Nurses’ Note
1535: Client returned from hemodialysis via stretcher to assigned room. The client was alert, oriented x 4. Denied any pain. He stated he felt ‘tired and dizzy.’ The client reported that the dizziness occurred when he quickly changed positions. The client was assessed, and vital signs were obtained.

Vital Signs
• Temperature 97° F (36° C)
• Pulse 94/minute; irregular
• Respirations 14/minute
• Blood Pressure 91/58 mm Hg
• Oxygen saturation 92% on room air

Assessment
Neurological:
Alert and completely oriented; reports dizziness. Pupils, equal, round, and reactive to light.
Cardiovascular:
Peripheral pulses intact; no edema; S1/S2 heart tones. Positive bruit and thrill in left arm A/V fistula. Gauze dressing applied which is dry with a scant amount of dry blood
Respiratory:
Diminished lung sounds, occasional cough
GI/GU:
Normoactive bowel sounds in all quadrants. Anuria.
Skin:
Warm and dry

Medical History
• End-stage renal disease (ESRD)
• Uncontrolled hypertension
• Chronic obstructive pulmonary disease
• Atrial fibrillation


Question 1 of 5

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.

Correct Answer: C,D,E,G

Rationale: Irregular pulse, low blood pressure (91/58 mmHg), dizziness, and anuria indicate potential cardiovascular and renal complications post-hemodialysis.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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