Nokea
A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should?
- A. Assess the dialysis access for a bruit and thrill.
- B. Insert an indwelling urinary catheter and drain all urine from the bladder.
- C. Ask the client to turn toward the left side.
- D. Warm the solution in the warmer.
Correct Answer: D
Rationale: Warming the dialysis solution prevents discomfort and promotes effective dialysis by relaxing abdominal muscles.
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How often should the postoperative client's temperature be assessed during the first 24 hours after surgery?
- A. Every 2 hours.
- B. Every 4 hours.
- C. Every 6 hours.
- D. Every 8 hours.
Correct Answer: B
Rationale: Assessing temperature every 4 hours in the first 24 hours detects fever early, indicating potential infection or other complications.
Which of the following findings should the nurse report to the client's physician for a client with unstable type 1 diabetes mellitus? Select all that apply.
- A. Systolic blood pressure, 145 mm Hg.
- B. Diastolic blood pressure, 87 mm Hg.
- C. High-density lipoprotein (HDL), 30 mg/dL.
- D. Glycosylated hemoglobin (HbA1c), 10.2%.
- E. Triglycerides, 425 mg/dL.
- F. Urine ketones, negative.
Correct Answer: A,C,D,E
Rationale: Systolic hypertension (145 mm Hg), low HDL (30 mg/dL), high HbA1c (10.2%), and elevated triglycerides (425 mg/dL) indicate poor control and cardiovascular risk, requiring reporting. Normal diastolic pressure and negative ketones are not concerning.
A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Encourage the client to cough and deep breathe.
- C. Auscultate the lungs to detect abnormal breath sounds.
- D. Contact the physician.
Correct Answer: D
Rationale: Sudden dyspnea, tachypnea, and chest discomfort suggest a pulmonary embolism, a medical emergency. Contacting the physician first ensures rapid intervention. Elevating the bed, encouraging coughing, or auscultating lungs delays critical treatment.
During the initial stage of adaptation to the diagnosis of cancer and its treatment, the nurse can facilitate the client's adaptation by:
- A. Encouraging the client to maintain her usual role.
- B. Facilitating family-related disagreements and conflicts.
- C. Supporting the client in her use of denial as a coping strategy.
- D. Arranging transportation and child care on treatment days.
Correct Answer: D
Rationale: Arranging transportation and child care addresses practical barriers, facilitating the client's ability to focus on treatment and adapt to the diagnosis.
A client has just had an inguinal herniorrhaphy. Which of the following instructions would be most appropriate to include in his discharge plan?
- A. Turning, coughing, and deep breathing every 2 hours.
- B. Applying an ice bag to the scrotum.
- C. Raising the scrotum with a support.
- D. Remaining in a high Fowler's position while resting.
Correct Answer: B
Rationale: Applying an ice bag to the scrotum reduces swelling and discomfort post-inguinal herniorrhaphy. Turning and breathing are general postoperative care, scrotal support is not specified, and high Fowler's position is not necessary. CN: Physiological adaptation; CL: Synthesize