Nokea
A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
- A. Warmed solution helps keep the body temperature maintained within a normal range during instillation
- B. Warmed solution helps dilate the peritoneal blood vessels
- C. Warmed solution decreases the risk of peritoneal infection
- D. Warmed solution promotes a relaxed abdominal muscle
Correct Answer: B
Rationale: Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. Relaxing the abdominal muscles does not facilitate peritoneal dialysis.
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An amniocentesis at 32 weeks gestation reveals that a multigravida with diabetes has an L/S ratio of 1:1 with the presence of phosphatidylglycerol. Based on the amniocentesis,the nurse knows that if delivered now:
- A. The newborn is at low risk for congenital anomalies.
- B. The newborn is at high risk for intrauterine growth retardation.
- C. The newborn is at high risk for respiratory distress syndrome.
- D. The newborn is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 at 32 weeks indicates immature fetal lungs increasing the risk of respiratory distress syndrome (RDS) if delivered now. Phosphatidylglycerol presence is positive but does not fully mitigate RDS risk. The other risks are not directly related to the L/S ratio.
Which finding in the patient's history contraindicates the use of Imitrex (sumatriptan) for the prevention of migraine headaches?
- A. Diabetes
- B. Angina
- C. Renal calculi
- D. Peptic ulcer disease
Correct Answer: B
Rationale: Sumatriptan (Imitrex) is a vasoconstrictor contraindicated in patients with angina due to the risk of coronary artery vasoconstriction and ischemia. Diabetes renal calculi and peptic ulcer disease are not contraindications for sumatriptan.
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
- A. Give fluids if the client requests them.
- B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
- C. Measure vital signs at least every 4 hours.
- D. Release restraints every 2 hours for client to exercise.
Correct Answer: D
Rationale: Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
The nurse is performing discharge teaching on a client at high risk for the development of skin cancer. Which instruction should be included in the client teaching?
- A. "You should see the doctor every six months."
- B. "Sunbathing should be done between the hours of noon and 3 p.m."
- C. "If you have a mole, it should be removed and biopsied."
- D. "You should wear sunscreen when going outside."
Correct Answer: D
Rationale: Wearing sunscreen protects against UV radiation, a key skin cancer risk factor. Regular checkups (A) are less specific, sunbathing at peak hours (B) increases risk, and routine mole removal (C) is excessive.
A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
- A. Perform massage of the stoma three times a day.
- B. Include high-fiber foods in the diet, especially nuts.
- C. Limit fluid intake to prevent loose stools.
- D. Cleanse the peristomal skin meticulously.
Correct Answer: D
Rationale: Meticulous cleansing of the peristomal skin prevents irritation and infection, essential for ileostomy care. Stoma massage (A) is unnecessary, high-fiber foods like nuts (B) may cause blockages, and limiting fluids (C) risks dehydration.