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    Nclex-Rn Readiness Test 1Question 54
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    Adult Health

    1355: Client was brought to the ED by the client's adult children, who reported that while she was visiting, she reported dizziness and seemed slightly confused. The adult child reports that the symptoms started one day ago. The client recently had a change in her blood pressure medication, with the physician increasing the dosage of her prescribed furosemide. Medical history of hypertension, hyperlipidemia, and osteoarthritis. Vital signs: T 100° F (37.8° C), P 104, RR 22, BP 110/66, pulse oximetry reading 95% on room air.

    On assessment, the client is lethargic and oriented to person and place, but not time. The client's breathing appears unlabored with tachypnea. Clear lung sounds throughout all lung fields. Skin is warm, dry, and flaky. Peripheral pulses 1+ in all extremities. Aching pain reported in the hips and knees and rated 5 on a scale of 0 (no pain) to 10 (severe pain). Client was ambulated to the bathroom, where she urinated 300 mL of clear, yellow urine without any odor or particulates. 22-gauge peripheral venous access device (VAD) placed in right forearm.

    ➢ Complete the sentence below by choosing from the list of options

    Based on the client's [lung sounds / urine characteristics / vital signs] and [pain level / dosage increase of diuretic / lung sounds] this client is at highest risk for [urinary infection. / fluid volume deficit. / fluid volume overload.]

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