Nokea
A client developed shock after a severe myocardial infarction and has now developed acute renal failure. The nurse should base the response on the knowledge that there was:
- A. A decrease in the blood flow through the kid-
- B. An obstruction of urine flow from the kidneys.
- C. A blood clot formed in the kidneys.
- D. A structural damage to the kidney resulting in acute tubular necrosis.
Correct Answer: A
Rationale: Decreased renal blood flow from shock post-myocardial infarction reduces kidney perfusion, leading to acute renal failure.
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When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which of the following information in the discharge plan? Select all that apply.
- A. Report signs of infection to health care provider.
- B. Keep the affected leg and foot on the floor when sitting in a chair.
- C. Remove anti-embolism stockings daily for laundering.
- D. None of the above
Correct Answer: A
Rationale: Reporting infection signs is critical to prevent complications. Elevating the leg when sitting and keeping stockings on reduce swelling and thrombosis risk.
When using a Doppler instrument to assess peripheral pulses, the correct placement of the transducer is important because it is difficult to differentiate between:
- A. Arterial and capillary blood flow
- B. Arterial and venous blood flow
- C. Arterial and arteriole blood flow
- D. Capillary and venous blood flow
Correct Answer: B
Rationale: Doppler ultrasound can detect both arterial (pulsatile) and venous (continuous) blood flow, but incorrect transducer placement may confuse these signals. Differentiating arterial from venous flow is critical in PVD assessment to confirm arterial patency. Capillary or arteriole flow is less relevant in this context.
A male client with a head injury regains consciousness and the normal loss. Which of the following nursing statements is most appropriate as the client awakens?
- A. I'll get your family.
- B. Can you tell me your name and where you live?
- C. I'll bet you're a little confused right now.
- D. You are in the hospital. You were in an accident and unconscious.
Correct Answer: D
Rationale: Providing clear, concise orientation information is most appropriate for a client regaining consciousness to reduce confusion and anxiety. Calling family, asking for personal details, or assuming confusion may overwhelm or distress the client.
What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
The most common issue associated with sleep disturbances in the hospitalized client with cancer is:
- A. Social.
- B. Nutritional.
- C. Cultural.
- D. Psychological.
Correct Answer: D
Rationale: Psychological factors, such as anxiety or fear related to cancer diagnosis and treatment, are the most common causes of sleep disturbances in hospitalized cancer patients.