Nokea
A client on hemodialysis reports fatigue. The nurse should assess for:
- A. Anemia.
- B. Hyperkalemia.
- C. Dehydration.
- D. Infection.
Correct Answer: A
Rationale: Anemia is common in renal failure due to decreased erythropoietin.
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What should the nurse monitor in a client receiving baclofen?
- A. Blood pressure.
- B. Spasticity levels.
- C. Blood glucose.
- D. Respiratory rate.
Correct Answer: B
Rationale: Spasticity levels are monitored to evaluate the effectiveness of baclofen in reducing muscle spasticity.
A client has been in the position shown in the figure for surgery. The nurse should document that the client has been in which of the following positions?
- A. Reverse Trendelenburg.
- B. Low Fowler’s.
- C. High lithotomy.
- D. Prone.
Correct Answer: C
Rationale: The client is in the lithotomy position. The reverse Trendelenburg position is when the client is lying supine with the head lower than the rest of the body. A low Fowler’s position is when the client is sitting up at a 30- to 45-degree angle. The prone position is when the client is lying face down.
A client with neutropenia is at risk for sepsis. Which of the following is the earliest sign the nurse should monitor for?
- A. Hypotension.
- B. Tachycardia.
- C. Oliguria.
- D. Confusion.
Correct Answer: B
Rationale: Tachycardia is often the earliest sign of sepsis, reflecting the body's response to infection, and requires prompt monitoring in a neutropenic client.
Before undergoing a transsphenoidal hypophysectomy, the client asks the nurse how the surgeon will close the incision made in the dura. The nurse should respond based on the knowledge that:
- A. Dissolvable sutures are used to close the dura.
- B. Nasal packing provides pressure until normal wound healing occurs.
- C. A patch is made with a piece of fascia.
- D. A synthetic mesh is placed to facilitate healing.
Correct Answer: C
Rationale: A fascial patch is commonly used to repair the dura during transsphenoidal hypophysectomy to prevent CSF leaks.
The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a:
- A. Low sodium level.
- B. High glucose level.
- C. High calcium level.
- D. Low potassium level.
Correct Answer: D
Rationale: Low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing digoxin's binding to cardiac cells, leading to arrhythmias.