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A client has been diagnosed with renal failure and is admitted for dialysis. Which of the ff is the nurse's responsibility as the client undergone dialysis?
- A. Keeping dialysis supplies in a clean area
- B. Inspecting the catheter insertion site for signs of infection
- C. Weighing the client before and after the procedure
- D. washing hands before and after handling the catheter
Correct Answer: C
Rationale: The nurse's responsibility during dialysis includes weighing the client before and after the procedure. This is important to monitor the amount of fluid removed during dialysis and to ensure that the client's fluid balance is managed properly. It helps in determining the effectiveness of dialysis treatment in removing excess fluid from the body. Keeping the client's fluid balance in check is crucial in managing renal failure and preventing complications such as fluid overload. Therefore, monitoring the client's weight before and after dialysis is a key responsibility of the nurse in this situation.
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For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
- A. Administering aspirin if the temperature exceeds 102â—‹1 F (38.8â—‹0 C)
- B. inspecting the skin for petechiae once every shift
- C. providing for frequent rest periods
- D. Placing the client in strict isolation
Correct Answer: C
Rationale: Providing for frequent rest periods is the most appropriate intervention for a client newly diagnosed with radiation-induced thrombocytopenia. Thrombocytopenia is characterized by a decreased number of platelets, which are essential for blood clotting. Clients with thrombocytopenia are at an increased risk for bleeding and bruising. Therefore, it is important to prevent activities that may lead to injury or bleeding. Providing frequent rest periods allows the client to conserve energy and minimize the risk of trauma that could lead to bleeding complications. This intervention helps manage the symptoms associated with thrombocytopenia and promotes the client's safety and well-being.
The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?
- A. Prehypertension
- B. Stage 2
- C. Stage 1
- D. Posthypertension
Correct Answer: B
Rationale: According to the guidelines by the American Heart Association (AHA), the patient's blood pressure readings of 164/102 and 176/100 on two separate occasions fall in the Stage 2 hypertension category. Stage 2 hypertension is defined as a systolic blood pressure of 140 mm Hg or higher, or a diastolic blood pressure of 90 mm Hg or higher. The readings provided are significantly above these thresholds, indicating severe hypertension that requires prompt medical attention and management to reduce the risk of complications such as heart disease, stroke, and kidney damage. It is important for healthcare providers to closely monitor and intervene in cases of Stage 2 hypertension to prevent further health complications.
The kidneys regulate acid-base balance by all of the following mechanisms except:
- A. Excreting hydrogen ions (H )
- B. Reabsorbing carbon dioxide into the
- C. Reabsorbing or excreting HCO into blood
- D. retaining hydrogen ions
Correct Answer: B
Rationale: The kidneys help regulate acid-base balance through several mechanisms, including excreting hydrogen ions (H+), reabsorbing or excreting bicarbonate (HCO3-) into the blood, and retaining or excreting hydrogen ions. However, the kidneys do not play a direct role in reabsorbing carbon dioxide into the blood. Carbon dioxide is mainly managed in the body through the respiratory system, where it is exhaled as a waste product of metabolism.
A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
- A. The client's diet
- B. The client's family member's history of
- C. The client's drug history chronic diseases
- D. The client's ability to produce antibodies
Correct Answer: D
Rationale: Assessing the client's ability to produce antibodies is a crucial factor in determining immune system function. Antibodies are proteins produced by the immune system to help fight off infections and other harmful substances. In a male client suspected of an immune system disorder, understanding his ability to produce antibodies can provide valuable insights into the functionality of his immune system. This assessment can help healthcare providers identify potential deficiencies or abnormalities in the immune response, leading to appropriate diagnosis and treatment strategies.
Which of the following malignancies is least likely to occur in a 10-month-old infant?
- A. neuroblastoma
- B. nephroblastoma
- C. retinoblastoma
- D. hepatoblastoma
Correct Answer: D
Rationale: Hepatoblastoma is rare in infants under 1 year old, being more common in toddlers.