Nokea
A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:
- A. Hypotriglyceridemia
- B. Abdominal hernia
- C. Anorexia
- D. Peritonitis
Correct Answer: A
Rationale: Peritoneal dialysis poses risks of various complications, including abdominal hernia, anorexia, peritonitis, and other issues. However, hypotriglyceridemia is not a common complication associated with peritoneal dialysis. The nurse should focus on educating the client about the risks of developing peritonitis, abdominal hernias, anorexia, low back pain, and abdominal bleeding. Monitoring triglyceride levels is essential for managing lipid disorders but is not directly linked to peritoneal dialysis complications.
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The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
- A. Supine with the head of the bed elevated 30 degrees
- B. In a high-Fowler's position with the left arm extended
- C. On the right side with the left arm extended above the head
- D. Sitting upright with the arms supported on an overbed table
Correct Answer: D
Rationale: The correct position for a patient with a left-sided pleural effusion undergoing thoracentesis is sitting upright with the arms supported on an overbed table. This position helps increase lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space making access to the pleural space easier. Placing the patient supine, in a high-Fowler's position, or on the right side with the left arm extended above the head could increase the work of breathing for the patient and complicate the thoracentesis procedure for the healthcare provider.
A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
- A. Assist with active range of motion (ROM).
- B. Observe for agitation and paranoia.
- C. Give muscle relaxants as needed to reduce spasms.
- D. Use simple words and phrases to explain procedures.
Correct Answer: A
Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?
- A. Increased tactile fremitus
- B. Dry, nonproductive cough
- C. Hyperresonance to percussion
- D. A grating sound on auscultation
Correct Answer: A
Rationale: Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias, such as pneumococcal pneumonia. Dullness to percussion would be expected due to consolidation. Pneumococcal pneumonia typically presents with a loose, productive cough rather than a dry, nonproductive cough. Hyperresonance to percussion is not a typical finding in pneumonia and may suggest conditions like emphysema. Adventitious breath sounds such as crackles and wheezes are typical in pneumonia, but a grating sound on auscultation is more representative of a pleural friction rub rather than pneumonia.
The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. What action should the nurse take next?
- A. Auscultate anterior and posterior breath sounds bilaterally
- B. Encourage the patient to turn, cough, and deep breathe
- C. Review the chest x-ray report for evidence of pneumonia
- D. Palpate the anterior chest and observe for barrel chest
Correct Answer: A
Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99'. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with conditions like pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Encouraging the patient to turn, cough, and deep breathe is an appropriate intervention for atelectasis, but assessing breath sounds takes priority. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). Palpating the anterior chest for fremitus is less effective due to the presence of large muscles and breast tissue, making auscultation a more appropriate next step.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
- A. Weak, nonproductive cough effort
- B. Large amounts of greenish sputum
- C. Respiratory rate of 28 breaths/minute
- D. Resting pulse oximetry (SpO2) of 85%
Correct Answer: A
Rationale: The correct answer is 'Weak, nonproductive cough effort.' A weak, nonproductive cough indicates that the patient is unable to clear the airway effectively, supporting the nursing diagnosis of ineffective airway clearance. In pneumonia, secretions can obstruct the airway, leading to ineffective clearance. Choices B, C, and D do not directly reflect ineffective airway clearance. Large amounts of greenish sputum (Choice B) may suggest infection or inflammation but do not specifically indicate ineffective airway clearance. The respiratory rate of 28 breaths/minute (Choice C) and a resting pulse oximetry (SpO2) of 85% (Choice D) are more indicative of impaired gas exchange or respiratory distress rather than ineffective airway clearance.