Nokea
A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions is appropriate when caring for this access site?
- A. Assess for clotting in fistula tubing
- B. Apply a dressing over the fistula site
- C. Assess for a bruit or thrill at the site of the fistula
- D. Assess circulation proximal to the fistula site
Correct Answer: A
Rationale: When caring for an AV fistula used for hemodialysis, it is important to assess for a bruit (a humming sound) or thrill (a vibrating sensation) at the site of the fistula. These indicate proper blood flow through the fistula, ensuring it is patent and suitable for hemodialysis. Assessing for clotting in fistula tubing (Choice A) is not a routine nursing intervention for AV fistulas. Applying a dressing over the fistula site (Choice B) is not necessary as the site needs to be accessible for hemodialysis. Assessing circulation proximal to the fistula site (Choice D) is important but not specific to caring for the access site of an AV fistula.
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A client is brought into the emergency room where the physician suspects that he has cardiac tamponade. Based on this diagnosis, the nurse would expect to see which of the following signs or symptoms in this client?
- A. Fever, fatigue, malaise
- B. Hypotension and distended neck veins
- C. Cough and hemoptysis
- D. Numbness and tingling in the extremities
Correct Answer: B
Rationale: Cardiac tamponade occurs when fluid or blood accumulates in the pericardium, preventing the heart from contracting properly. This leads to decreased cardiac output and is considered a medical emergency. Classic signs of cardiac tamponade include hypotension (low blood pressure) and distended neck veins due to the increased pressure around the heart. These signs result from the compromised ability of the heart to pump effectively. Choices A, C, and D are not typically associated with cardiac tamponade. Fever, fatigue, and malaise are non-specific symptoms that can be seen in various conditions. Cough and hemoptysis are more commonly associated with respiratory conditions, while numbness and tingling in the extremities are neurological symptoms not typically seen in cardiac tamponade.
An 85-year-old male has been losing mobility and gaining weight over the last two months. The patient also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests is most likely to be performed?
- A. CBC (complete blood count)
- B. ECG (electrocardiogram)
- C. Thyroid function tests
- D. CT scan
Correct Answer: C
Rationale: The symptoms of weight gain and poor temperature tolerance in an elderly male suggest a potential thyroid dysfunction. Thyroid function tests are crucial in differentiating between hyperthyroidism, hypothyroidism, and a euthyroid state. These tests involve measuring the serum levels of thyroid hormones T3 and T4, also known as thyroxine, to evaluate thyroid function accurately. A complete blood count (Choice A) would not directly address the symptoms presented. An electrocardiogram (Choice B) assesses heart activity and would not be the primary test for these symptoms. A CT scan (Choice D) provides detailed images of internal organs and structures, which would not be the initial investigation for the described symptoms.
A 24-year-old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Based on the presenting signs and symptoms, which of the following would you most likely suspect?
- A. Diverticulosis
- B. Hypercalcemia
- C. Hypocalcemia
- D. Irritable bowel syndrome
Correct Answer: B
Rationale: The correct answer is Hypercalcemia. In this case, the patient's history of myeloma, constipation, intense abdominal pain, and polyuria suggests hypercalcemia. Elevated calcium levels can lead to polyuria, severe abdominal pain, and confusion. Diverticulosis (Choice A), characterized by small pouches in the colon wall, typically does not present with confusion and polyuria. Hypocalcemia (Choice C) is unlikely given the symptoms described. Irritable bowel syndrome (Choice D) does not typically cause confusion and polyuria as seen in hypercalcemia.
What intervention should the nurse implement while a client is having a grand mal seizure?
- A. Open the jaw and place a bite block between the teeth
- B. Try to place the client on his side
- C. Restrain the client to prevent injury
- D. Place pillows around the client
Correct Answer: B
Rationale: During a grand mal seizure, the client is at risk of injury due to severe, involuntary muscle spasms and contractions. It is crucial for the nurse to avoid restraining the client or inserting objects into their mouth, as these actions may lead to further harm. Placing the client on their side can help facilitate the drainage of oral secretions and assist in maintaining an open airway, reducing the risk of aspiration. Restraint should be avoided as it can exacerbate muscle contractions and increase the risk of injury. Placing pillows around the client may not provide adequate support or protection during the seizure, making it a less effective intervention compared to positioning the client on their side.
A patient has a history of photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select one that doesn't apply
- A. Ciprofloxacin (Cipro)
- B. Sulfonamide
- C. Norfloxacin (Noroxin)
- D. Nitro-Dur patch
Correct Answer: D
Rationale: Nitro-Dur patch is not associated with photosensitive reactions. It is used to prevent chest pain or angina, and common side effects include headache, lightheadedness, nausea, and flushing. Choices A, B, and C are known to cause photosensitive reactions. Ciprofloxacin (Cipro), Sulfonamides, and Norfloxacin (Noroxin) are drugs that are commonly associated with photosensitivity reactions. Patients taking these medications should be advised to avoid direct sunlight and use sun protection to prevent skin reactions.