Nokea
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. Crohn's disease with colectomy.
- B. Latent hepatitis C.
- C. Type 2 diabetes mellitus.
- D. Nephrotic syndrome history.
Correct Answer: A
Rationale: Crohn's disease with colectomy is a contraindication for peritoneal dialysis due to the risk of infection or inadequate dialysis from compromised peritoneal integrity.
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The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?
- A. Protect the skin of the radiation portal site from sunlight exposure.
- B. Avoid washing the skin inside the radiation portal site.
- C. Remove the ink marks of the portal after each radiation treatment.
- D. Apply moisture lotions daily to the radiation portal site.
Correct Answer: A
Rationale: Protecting the radiation portal site from sunlight exposure prevents further damage to the sensitive irradiated skin.
When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?
- A. Eat a bland diet and avoid spicy foods.
- B. Have small frequent meals and sit up for at least two hours after meals.
- C. Eat a soft diet with increased intake of milk and milk products.
- D. Eat a high fiber diet and increase fluid intake.
Correct Answer: D
Rationale: Eating a high-fiber diet and increasing fluid intake are key recommendations for managing diverticulosis, promoting regular bowel movements and preventing constipation.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Have the antifungal creams been effective?
- B. Do your family members share combs and brushes?
- C. Do you have any dry patches on your feet and hands?
- D. Has everyone at home already had varicella?
Correct Answer: D
Rationale: Asking whether everyone at home has had varicella is important, as herpes zoster can transmit the varicella-zoster virus to non-immune individuals, causing chickenpox.
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
- A. The client's blood pressure readings will be less than 160/90 mm Hg.
- B. The nurse will encourage the client to walk thirty minutes every day.
- C. The client's family will repeat signs and symptoms about the disease.
- D. The client's daily blood pressure will be less than 140/80 mm Hg this month.
Correct Answer: D
Rationale: Achieving a daily blood pressure reading of less than 140/80 mm Hg is an appropriate outcome to reduce cardiovascular complications, including those contributing to blurred vision.
A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump?
- A. 125
Correct Answer: A
Rationale: To calculate: 3000 mL / 24 hr = 125 mL/hr. The nurse should program the infusion pump to deliver 125 mL/hr.