Difficulty: Medium
Average Score: 66%
Simulated
Passage / Scenario
Nurses NotesDiagnostic Results
Medical History
Vital Signs
ProviderÔÇÖs Prescriptions
Over the past 2 months, the client has noticed a significant decrease in his ability to perform daily activities due to fatigue. He also reports a 24-hour history of fever, chills, and weakness. There is erythema around the arteriovenous fistula (AVF) site on his right arm. The client states, ÔÇ£IÔÇÖve been having difficulty breathing.ÔÇØ On examination, his breath sounds are clear. He reports no cough. Bowel sounds are active in all four quadrants. He reports no diarrhea and had his last bowel movement yesterday. The client also reports anuria.
A nurse in a providerÔÇÖs office is caring for a 68-year-old male client who reports changes in activity tolerance, feeling tired all the time, and difficulty remembering things. The client also states they bruise easily.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, what actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct answer
D,E,F
Rationale
The client's symptoms of fever, chills, weakness, erythema around the AVF site, and anuria suggest sepsis, likely related to an infection at the fistula site. The nurse should administer IV fluids to maintain circulation and monitor oxygen saturation to ensure adequate oxygenation, addressing potential septic shock. Monitoring blood pressure and temperature assesses hemodynamic stability and infection control progress.