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A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?
- A. Joint pain.
- B. Hematuria.
- C. Muscle atrophy.
- D. Low grade fever.
Correct Answer: B
Rationale: Hematuria indicates potential lupus nephritis, a serious renal complication requiring urgent evaluation.
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A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with 0.9% sodium chloride is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Decrease the flow rate.
- B. Irrigate the catheter manually.
- C. Discontinue infusing solution.
- D. Monitor catheter drainage.
Correct Answer: B
Rationale: Manual irrigation clears clots, maintaining catheter patency and preventing obstruction post-TURP.
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Administer pain medication at designated Intervals around the clock.
- B. Assess the pulses proximal to the fracture site.
- C. Remove traction every shift and provide skin care.
- D. Assess the pin sites for signs of infection.
Correct Answer: D
Rationale: Assessing pin sites for infection is critical in skeletal traction to prevent complications like osteomyelitis, which could delay healing.
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
- A. Latent hepatitis C.
- B. Nephrotic syndrome history.
- C. Type 2 diabetes mellitus.
- D. Crohn's disease with colectomy.
Correct Answer: D
Rationale: Crohn's with colectomy contraindicates peritoneal dialysis due to altered abdominal anatomy, increasing infection risk.
A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?
- A. Use a space heater to keep the workspace warm.
- B. Take a multivitamin that contains vitamin D daily.
- C. Keep both hands elevated during work breaks.
- D. Obtain a keyboard designed to limit wrist flexion.
Correct Answer: A
Rationale: A warm workspace prevents vasospasm, reducing Raynaud's attacks during work.
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Increase Intake of potassium rich foods such as bananas or cantaloupe.
- B. Restrict protein intake by limiting meats and other high protein foods.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of high fiber foods, such as bran cereal.
Correct Answer: B
Rationale: Restricting protein reduces kidney workload and proteinuria, preserving function in glomerulonephritis.