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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. Crohn's disease with colectomy.
- C. History of nephrotic syndrome.
- D. Type 2 diabetes mellitus.
Correct Answer: B
Rationale: Crohn's disease with colectomy creates peritoneal adhesions, making peritoneal dialysis unsuitable.
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The nurse is providing discharge teaching to an older patient hospitalized for treatment of venous leg ulcers. What instructions should the nurse include in the teaching plan?
- A. The patient should eat a diet high in protein and vitamins A and C.
- B. The patient should keep their legs elevated when sitting or lying down.
- C. The patient should maintain as much bed rest as possible.
- D. The patient should inspect their ankles daily for areas of darkening skin.
- E. The patient should apply intermittent cold compresses four times daily.
Correct Answer: A,B,D
Rationale: A diet high in protein and vitamins A and C, leg elevation, and daily ankle inspections support healing and early detection of complications in venous leg ulcers.
A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?
- A. Lumbar puncture.
- B. Skull radiography.
- C. Magnetic resonance imaging (MRI).
- D. Computerized tomography (CT) scan.
Correct Answer: A
Rationale: A lumbar puncture is essential for confirming bacterial meningitis by analyzing cerebrospinal fluid, making it the priority diagnostic procedure.
An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient's response to treatment?
- A. Urinary output.
- B. Skin elasticity.
- C. Pain scale.
- D. Lung sounds.
- E. Oxygen saturation.
Correct Answer: A,D,E
Rationale: Assessing urinary output, lung sounds, and oxygen saturation evaluates furosemide's effectiveness in reducing fluid overload and improving respiratory status.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. White blood cell count.
- B. Platelet count.
- C. Red blood cell count.
- D. Hemoglobin levels.
Correct Answer: B
Rationale: Platelet count is critical as low levels cause petechiae and ecchymosis due to bleeding tendencies.
A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?
- A. Painful areas should be rubbed gently until the pain subsides.
- B. Wearing gloves when handling cold items guards against painful spasms.
- C. Return appointments will be needed for IV pain medication.
- D. Enrolling in a pain clinic can provide pain relief alternatives.
Correct Answer: B
Rationale: Wearing gloves prevents cold-induced spasms, reducing pain in Raynaud's disease.