Nokea
A client on peritoneal dialysis reports cloudy effluent. The nurse should:
- A. Continue the exchange.
- B. Notify the physician.
- C. Increase dwell time.
- D. Administer pain medication.
Correct Answer: B
Rationale: Cloudy effluent suggests peritonitis, requiring immediate medical attention.
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A client with a lumbar spinal fusion is preparing for discharge. Which activity should the nurse advise the client to avoid?
- A. Walking short distances daily.
- B. Lifting objects heavier than 10 pounds.
- C. Sleeping on a firm mattress.
- D. Using a recliner for sitting.
Correct Answer: B
Rationale: Lifting heavy objects can strain the surgical site, delaying healing post-spinal fusion.
Which of the following positions would be appropriate for a client with severe ascites?
- A. Fowler's.
- B. Side-lying.
- C. Reverse Trendelenburg.
- D. Sims.
Correct Answer: A
Rationale: Fowler's position (A) elevates the head, reducing diaphragm pressure from ascites and improving breathing. Side-lying (B), Reverse Trendelenburg (C), and Sims (D) are less effective for respiratory relief.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?
- A. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles.
- B. Confusion, urine output 15 mL over the last 2 hours, orthopnea.
- C. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
- D. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.
Correct Answer: B
Rationale: Confusion, low urine output, and orthopnea indicate severe heart failure with potential cerebral and renal hypoperfusion, requiring immediate intervention. Other options reflect stable or less urgent findings.
The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or fluid loss, requiring urgent physician attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical.
A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, 'Why does she have this tube inserted in her hip?' Which of the following responses would be best?
- A. The tube helps us to detect a wound infection early on.'
- B. This way we won't have to irrigate the wound.'
- C. Fluid won't be allowed to accumulate at the site.'
- D. We have a way to administer antibiotics into the wound.'
Correct Answer: C
Rationale: The drainage tube prevents fluid accumulation, reducing infection risk and promoting healing.