Nokea
The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis?
- A. air embolism
- B. clotting of the graft site
- C. dialysis encephalopathy
- D. disequilibrium syndrome
Correct Answer: D
Rationale: Disequilibrium syndrome causes tachypnea, hypotension, and anxiety due to rapid shifts in fluid and electrolytes during dialysis.
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The nurse is caring for a client who just returned from a total hip arthroplasty. A student nurse is helping provide care for this client. Which action by the student nurse requires intervention by the nurse?
- A. The student nurse floats the client's heels with a pillow.
- B. The student nurse positions the client with the legs adducted.
- C. The student nurse applies the sequential compression device (SCD) per orders.
- D. The student nurse encourages deep breathing and incentive spirometer use every 2 hours.
Correct Answer: B
Rationale: Adducting the legs post-hip arthroplasty risks dislocation; legs should be kept abducted. Other actions (A, C, D) are appropriate for preventing complications.
A young child with a rash that's raised and has circumscribed areas filled with fluid comes to the school nurse. What type of rash should the nurse document?
- A. maculopapular rash
- B. heat rash
- C. vesicular rash
- D. pustular rash
Correct Answer: C
Rationale: A rash with raised, fluid-filled, circumscribed areas is a vesicular rash (C), as seen in conditions like chickenpox. Maculopapular (A) is flat/spotted, heat rash (B) is prickly, and pustular (D) contains pus.
The nurse is teaching a client and her family about home care following a laryngectomy. Which statement by the client indicates a need for further teaching from the nurse?
- A. I will purchase a Medic-Alert bracelet.
- B. I can wear loose-fitting turtlenecks to cover the stoma.
- C. I can resume water aerobics once my doctor says it is okay.
- D. I have a lot of green houseplants year-round throughout my home.
Correct Answer: C
Rationale: Water aerobics pose a drowning risk due to water entering the stoma, requiring further teaching. Other statements are appropriate for laryngectomy care.
The nurse is reviewing arterial blood gases (ABGs) on a client. Which finding would prompt the nurse to notify the health care provider?
- A. pH 7.42
- B. pH 7.67
- C. HCO3 24 mEq/L
- D. paCO2 41 mmHg
- E. paCO2 44 mmHg
Correct Answer: B
Rationale: pH 7.67 indicates alkalosis (normal 7.35-7.45), requiring provider notification. Other values are within normal ranges (HCO3 22-26, paCO2 35-45).
While preparing a client for a colonoscopy, the nurse would be correct to implement which interventions? Select all that apply.
- A. instruction on high fiber diet the day before the procedure
- B. instruction that a sedative will be administered before the procedure
- C. instruction not to eat or drink 6-12 hours before the procedure
- D. instruction not to eat or drink 18 hours before the procedure
Correct Answer: B,C
Rationale: A sedative (B) is used for comfort, and fasting 6-12 hours (C) ensures a clear colon for colonoscopy. High fiber (A) is contraindicated, and 18 hours (D) is excessive.