Nokea
A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Take vital signs.
- C. Establish an I.V. access site.
- D. Call the admitting physician for orders.
- E. Contact the hemodialysis unit.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.
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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.
Which intervention is most effective for a client with MS-related vision impairment?
- A. Provide bright lighting.
- B. Use large-print materials.
- C. Limit visual activities.
- D. Wear dark glasses.
Correct Answer: B
Rationale: Large-print materials support clients with MS-related vision impairment by improving readability.
Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?
- A. Incorporate physical exercise as tolerated into the daily routine.
- B. Monitor peak flow numbers after meals and at bedtime.
- C. Eliminate stressors in the work and home environment.
- D. Use sedatives to ensure uninterrupted sleep at night.
Correct Answer: A
Rationale: Regular exercise, as tolerated, improves lung function and overall health in asthma. Peak flow monitoring is typically done morning and evening. Eliminating all stressors is unrealistic. Sedatives may depress respiration and are not recommended.
A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following?
- A. Development of a cataract.
- B. Possible retinal degeneration.
- C. Part of the disease process.
- D. A coincidental occurrence.
Correct Answer: B
Rationale: Hydroxychloroquine can cause retinal toxicity, leading to vision changes. This is a known side effect requiring immediate medical evaluation.
A client states, 'I don't want any more tests. Who cares what kind of leukemia I have? I just want to be treated now.' Which is the nurse's best response?
- A. I'm sure you are frustrated and want to be well now.'
- B. Your treatment can be more effective if it is based on more specific information about your disease.'
- C. Now, you know the tests are necessary and that you are just upset right now.'
- D. I understand how you feel.'
Correct Answer: B
Rationale: The nurse should explain that specific tests help tailor treatment to the type of leukemia, improving effectiveness. This addresses the client's desire for treatment while emphasizing the importance of diagnostic clarity. The other responses are empathetic but do not provide a rationale for testing.