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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The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor of a client recovering from anesthesia. Which action should the nurse take?
- A. Prepare for defibrillation.
- B. Continue to monitor the rhythm.
- C. Prepare to administer lidocaine hydrochloride.
- D. Notify the primary health care provider immediately.
Correct Answer: B
Rationale: As an isolated occurrence, the PVC is not life-threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the primary health care provider needs to be notified. Defibrillation is done to treat ventricular fibrillation. Lidocaine hydrochloride is not needed to treat isolated PVCs; it may be used to treat frequent PVCs in a client who is symptomatic and is experiencing decreased cardiac output.
The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which interventions would be helpful for this type of incontinence? Select all that apply.
- A. Surgery
- B. Bladder retraining
- C. Scheduled toileting
- D. Dietary modifications
- E. Pelvic muscle exercises
- F. Intermittent catheterization
Correct Answer: B,C,D,E
Rationale: Urge incontinence is the involuntary passage of urine after a strong sense of the urgency to void. It is characterized by urinary urgency, often with frequency (more often than every 2 hours); bladder spasm or contraction; and voiding in either small amounts (less than 100 mL) or large amounts (greater than 500 mL). It can be caused by decreased bladder capacity, irritation of the bladder stretch receptors, infection, and alcohol or caffeine ingestion. Interventions to assist the client with urge incontinence include bladder retraining, scheduled toileting, dietary modifications such as eliminating alcohol and caffeine intake, and pelvic muscle exercises to strengthen the muscles. Surgery and urinary catheterization are invasive measures and will not assist in the treatment of urge incontinence.
The nurse creates a care plan for a client receiving hemodialysis through an arteriovenous (AV) fistula in the right arm. The nurse includes which interventions in the plan to protect the AV fistula from injury? Select all that apply.
- A. Assess pulses and circulation proximal to the fistula.
- B. Palpate for thrills and auscultate for a bruit every 4 hours.
- C. Check for bleeding and infection at hemodialysis needle insertion sites.
- D. Avoid taking blood pressure or performing venipunctures in the extremity.
- E. Instruct the client not to carry heavy objects or anything that compresses the extremity.
- F. Instruct the client not to sleep in a position that places her or his body weight on top of the extremity.
Correct Answer: B,C,D,E,F
Rationale: An AV fistula is an internal anastomosis of an artery to a vein and is used as an access for hemodialysis. The nurse should implement the following to protect the fistula: palpate for thrills and auscultate for a bruit every 4 hours, check for bleeding and infection at hemodialysis needle insertion sites, avoid taking blood pressures or performing venipunctures in the extremity, instruct the client not to carry heavy objects or anything that compresses the extremity, instruct the client not to sleep in a position that places the body weight on top of the extremity, and the nurse should assess pulses and circulation distal to the fistula.
A clinic nurse is caring for a client with a suspected diagnosis of gestational hypertension. The nurse assesses the client, expecting to note which set of findings if gestational hypertension is present?
- A. Edema, ketonuria, and obesity
- B. Edema, tachycardia, and ketonuria
- C. Glycosuria, hypertension, and obesity
- D. Elevated blood pressure and proteinuria
Correct Answer: D
Rationale: Gestational hypertension is the most common hypertensive disorder in pregnancy. It is characterized by the development of hypertension and proteinuria. Glycosuria and ketonuria occur in diabetes mellitus. Tachycardia and obesity are not specifically related to diagnosing gestational hypertension. Edema is not specific to gestational hypertension and can occur in many disorders.
The nurse prepares to transfer the client with a newly applied arm cast into the bed using which method?
- A. Placing ice on top of the cast
- B. Supporting the cast with the fingertips only
- C. Asking the client to support the cast during transfer
- D. Using the palms of the hands and soft pillows to support the cast
Correct Answer: D
Rationale: The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this would be done after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.