Nokea
A client who has experienced an acute kidney injury is prescribed a fluid restriction of 1500 mL per day. Which interventions will the nurse implement to assist the client in maintaining this restriction? Select all that apply.
- A. Removing the water pitcher from the bedside
- B. Using mouthwash with alcohol for mouth care
- C. Prohibiting beverages with sugar to minimize thirst
- D. Providing the client with lip balm to keep lips moist
- E. Offering the client ice chips at intervals during the day
Correct Answer: A,D,E
Rationale: The nurse can help the client maintain fluid restriction through a variety of means. The water pitcher should be removed from the bedside to aid in compliance. The use of ice chips and lip ointments is another intervention that may be helpful to the client on fluid restriction. Frequent mouth care is important; however, alcohol-based products should be avoided because they are drying to mucous membranes. Beverages that the client enjoys are provided and are not restricted based on sugar content.
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A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which measure should the nurse implement to promote client safety?
- A. Use the right arm blood pressure measurement.
- B. Use the fistula for all venipunctures and intravenous infusions.
- C. Ensure that small clamps are attached to the AV fistula dressing.
- D. Assess the fistula for the presence of a bruit and thrill every 4 hours.
Correct Answer: D
Rationale: AV fistulas are created by anastomosis of an artery and a vein within the subcutaneous tissues to create access for hemodialysis. Fistulas should be evaluated for presence of thrills (palpate over the area) and bruits (auscultate with a stethoscope) as an assessment of patency. Blood pressures or venipunctures are not done on the extremity with the fistula because of the risk of clotting, infection, or damage to the fistula. The fistula is not used for venipunctures or intravenous infusions for the same reason. Clamps may be needed for an external device such as an AV shunt, but the AV fistula is internal.
The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?
- A. Presence of a cephalhematoma
- B. Infant blood type of O negative
- C. Birth weight of 8 pounds 6 ounces
- D. A negative direct Coombs' test result
Correct Answer: A
Rationale: A cephalhematoma is swelling caused by bleeding into an area between the bone and its periosteum (does not cross over the suture line). Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves (usually within 6 weeks) and is absorbed into the circulatory system. The classic Rh incompatibility situation involves an Rh-negative mother with an Rh-positive fetus/newborn. The birth weight in option 3 is within the acceptable range for a term newborn and therefore does not contribute to an increased bilirubin level. A negative direct Coombs' test result indicates that there are no maternal antibodies on fetal erythrocytes.
The nurse is creating a plan of care for a client who has returned to the nursing unit after left nephrectomy. Which assessments should the nurse include in the plan of care? Select all that apply.
- A. Pain level
- B. Vital signs
- C. Hourly urine output
- D. Tolerance for sips of clear liquids
- E. Ability to cough and deep breathe
Correct Answer: A,B,C,E
Rationale: After nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the remaining kidney and detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could affect the client's ability to reposition, cough, and deep breathe. Therefore, the next most important measurements are vital signs, pain level, and ability to cough and deep breathe. Clear liquids are not given until the client has bowel sounds.
An echocardiogram, chest x-ray (CXR), and computed axial tomography (CAT) scan are prescribed for a client who has activity intolerance. In which order should the nurse plan to schedule the procedures to meet the needs of this client safely and effectively?
- A. CAT scan and CXR in the morning, and echocardiogram on the following morning
- B. CXR and echocardiogram together in the morning, and CAT scan in the afternoon of the same day
- C. Echocardiogram in the morning, and CXR and CAT scans together in the afternoon of the same day
- D. CXR in the morning, echocardiogram in the afternoon, and CAT scan in the morning of the following day
Correct Answer: D
Rationale: CAT scans are always performed in radiology, and CXR and echocardiograms can be done at the bedside; however, the best results usually occur when the test is performed in the related department. As long as the client is stable and transportation is provided, the nurse can schedule each procedure in its department with two procedures on the first day separated by a rest period, and the remaining procedure the next day.
The nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. Which finding should the nurse expect to note if this disorder was present?
- A. A dull red tympanic membrane
- B. A mobile tympanic membrane
- C. A transparent tympanic membrane
- D. A pearly colored tympanic membrane
Correct Answer: A
Rationale: Otoscopic examination of a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Options 2, 3, and 4 indicate normal findings in an otoscopic examination.