the nurse is taking the vital signs of a client after hemodialysis blood pressure is 11058 mm hg pulse 66 beatsmin and temperature is 998 f 376 c what
Logo

Nursing Elites

HESI RN

RN Medical/Surgical NGN HESI 2023

1. The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8°F (37.6°C). What is the most appropriate action by the nurse?

Correct answer: C

Rationale: After hemodialysis, it is crucial to monitor the client's temperature because the dialysate is warmed to increase diffusion and prevent hypothermia. The client's temperature might reflect the temperature of the dialysate. There is no need to administer fluids to increase blood pressure as the vital signs are within normal limits. Checking the white blood cell count or connecting the client to an ECG monitor is not necessary based on the information provided.

2. The nurse is caring for a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings should be reported immediately to the physician?

Correct answer: C

Rationale: Cloudy dialysate outflow should be reported immediately to the physician. It is indicative of peritonitis, a severe infection of the peritoneal cavity and a serious complication of peritoneal dialysis. Prompt medical attention is crucial to prevent further complications or systemic infection. Clear dialysate outflow (Choice A) is a normal finding in peritoneal dialysis. Increased blood pressure (Choice B) and decreased urine output (Choice D) are common in clients with chronic renal failure and may not require immediate reporting unless they are significantly abnormal or accompanied by other concerning symptoms.

3. Which of the following is a key symptom of myocardial infarction (MI)?

Correct answer: A

Rationale: The correct answer is A: Chest pain. Chest pain is a hallmark symptom of myocardial infarction (MI) due to inadequate blood flow to the heart muscle. This pain can be severe, crushing, or squeezing, and may radiate to the left arm, jaw, or back. Shortness of breath (choice B), nausea (choice C), and fatigue (choice D) can accompany MI but are not as specific or characteristic as chest pain in diagnosing this condition. Therefore, chest pain is the primary symptom to recognize for suspected MI.

4. The healthcare provider caring for a patient who will receive penicillin to treat an infection asks the patient about previous drug reactions. The patient reports having had a rash when taking amoxicillin (Amoxil). The healthcare provider will contact the provider to

Correct answer: B

Rationale: When a patient reports a previous rash with amoxicillin, which is a type of penicillin, there is a concern for a penicillin allergy. In such cases, using an alternative antibiotic like erythromycin, which is not a penicillin, is the appropriate approach to avoid potential cross-reactivity and allergic reactions. Giving smaller doses of penicillin does not address the underlying allergy issue and can still lead to severe hypersensitivity reactions. Diphenhydramine (Benadryl) is used to manage allergic reactions but should not be the first choice in changing the antibiotic. While some patients allergic to penicillins may also be allergic to cephalosporins like cefuroxime, it is not the best immediate alternative in this scenario.

5. In a client with congestive heart failure, the nurse would be correct in withholding a dose of digoxin without specific instruction from the healthcare provider if the client's

Correct answer: C

Rationale: The correct answer is C. Hypokalemia can precipitate digitalis toxicity in individuals on digoxin, increasing the risk of dangerous dysrhythmias. A serum potassium level of 3 mEq/L is below the normal range (3.5 to 5.5 mEq/L) and indicates hypokalemia, which can potentiate the effects of digoxin. Choices A, B, and D are not directly related to the potential for digitalis toxicity. Serum digoxin level of 1.5 ng/mL is within the therapeutic range, blood pressure of 104/68 mmHg is not a contraindication for administering digoxin, and an apical pulse of 68/min is within the normal range and not a reason to withhold digoxin.

Similar Questions

When a young client being taught to use an inhaler for asthma symptoms states the intention to use the inhaler but plans to continue smoking cigarettes, what is the best initial action by the nurse?
A client with chronic renal failure is receiving erythropoietin therapy. The nurse should assess the client for which of the following side effects?
A client is being prepared for transfer to the operating room. Which of the following actions should the nurse take in the care of this client at this time?
An emergency department nurse assesses a client with kidney trauma and notes that the client’s abdomen is tender and distended, and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation?
A client has an elevated blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses