Nokea
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 correct answer is C: Weighing the client before and after the procedure. This is crucial as it helps monitor fluid removal during dialysis, ensuring the process is effective and safe. Weighing helps determine if the correct amount of fluid has been removed.
A: Keeping dialysis supplies in a clean area is important for infection control but not a direct responsibility during the procedure.
B: Inspecting the catheter insertion site for signs of infection is essential for monitoring the site's health but not a direct responsibility during dialysis.
D: Washing hands before and after handling the catheter is a general infection control measure but not specific to the dialysis procedure itself.
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Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
- A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
- B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
- C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
- D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B
Rationale: The correct answer is B. Placing the patient on the side with support to the back, pillows for body alignment, and a washcloth to slightly curl the fingers helps prevent contractures, aids in maintaining proper alignment, and provides support for the affected side. This position also promotes optimal blood flow and prevents pressure sores.
Choice A is incorrect because tightly holding a rolled washcloth can restrict blood flow and cause discomfort. Choice C is incorrect as lying on the back with pillows under the head and knees does not address the specific needs of right-sided paralysis. Choice D is incorrect as trochanter rolls may not provide adequate support for the paralyzed side, and no pillows can lead to pressure sores and discomfort.
What equipment should the nurse prepare for the primary care provider when a woman says she is concerned about possible Chlamydia infection?
- A. Chlamydia slide
- B. Chlamydia collection kit
- C. Chlamydia swab
- D. Chlamydia wet mount
Correct Answer: B
Rationale: The correct answer is B: Chlamydia collection kit. The primary care provider will need the collection kit to gather a sample for testing. A Chlamydia slide (A) is not necessary as the provider needs to collect a sample first. A Chlamydia swab (C) is used to collect the sample, not to provide to the provider. A Chlamydia wet mount (D) is not appropriate for Chlamydia testing, as it is typically used for other types of infections.
A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?
- A. Clients with autoimmune disorders may have false-negative but not false-positive serologic tests
- B. Advanced medical interventions can cure most autoimmune disorders
- C. Autoimmune disorders include connective tissue (collagen) disorders
- D. Autoimmune disorders are distinctive, adding differential diagnosis
Correct Answer: C
Rationale: Correct Answer: C - Autoimmune disorders include connective tissue (collagen) disorders.
Rationale: Autoimmune disorders involve the immune system mistakenly attacking healthy cells and tissues in the body, which can lead to various conditions, including connective tissue disorders like rheumatoid arthritis. Providing this information to the client and family is crucial for understanding the nature of autoimmune disorders and the potential impact on the body.
Summary of other choices:
A: False-negative or false-positive serologic tests can occur in autoimmune disorders, so this statement is not specific enough to be the most appropriate information to provide.
B: Advanced medical interventions can manage symptoms but not cure autoimmune disorders, making this statement inaccurate and misleading.
D: Autoimmune disorders can present with a wide range of symptoms and can be challenging to diagnose, but this statement does not address the specific link between autoimmune disorders and connective tissue disorders.
Postural Hypotension is A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
- A. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
- B. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
- C. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
Correct Answer: A
Rationale: The correct answer is A because postural hypotension is defined as a drop in systolic blood pressure of greater than 20 mmHg or a drop in diastolic blood pressure of greater than 10 mmHg within 3 minutes of standing from a sitting or supine position. Therefore, a drop in systolic pressure greater than 10 mmHg when changing from lying to sitting is indicative of postural hypotension.
Choice B is incorrect as postural hypotension is primarily defined by changes in systolic blood pressure, not diastolic. Choice C is incorrect because a drop in diastolic pressure greater than 10 mmHg is not the defining characteristic of postural hypotension. Choice D is not provided.
A client with neuromuscular disorder is receiving intensive nursing care. The client is likely to face the risk for impaired skin integrity. Which of the ff must the nurse ensure to prevent skin breakdown in the client?
- A. Prevent strenuous exercises by the client
- B. Use pressure relieving devices when the client is in bed
- C. Place the client in Fowler’s position
- D. Avoid giving daily baths with soaps to the client
Correct Answer: B
Rationale: The correct answer is B: Use pressure relieving devices when the client is in bed. This is because pressure ulcers are a common risk for individuals with neuromuscular disorders due to immobility. Pressure relieving devices such as special mattresses or cushions help redistribute pressure and prevent skin breakdown.
Incorrect choices:
A: Preventing strenuous exercises is not directly related to preventing skin breakdown in this case.
C: Placing the client in Fowler's position may be beneficial for respiratory issues but does not directly address skin integrity.
D: Avoiding daily baths with soaps may lead to poor hygiene and does not specifically address the risk of skin breakdown.