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A client with a history of a kidney transplant is being discharged. The nurse should teach the client to:
- A. Monitor for signs of infection
- B. Eat a high-sodium diet
- C. Limit physical activity
- D. Take antibiotics daily
Correct Answer: A
Rationale: Immunosuppression post-kidney transplant increases infection risk, requiring vigilant monitoring. High-sodium diets, activity limits, and daily antibiotics are not standard.
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The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
- A. Assess the urinary output.
- B. Obtain arterial blood gases.
- C. Perform a dextrostick.
- D. Obtain a stool culture.
Correct Answer: A
Rationale: Potassium supplementation requires adequate renal function to prevent hyperkalemia. Assessing urinary output ensures the kidneys are functioning before adding potassium.
A client with a stroke and malnutrition has been placed on Total Parenteral Nutrition (TPN). The nurse notes air entering the client via the central line. Which initial action is most appropriate?
- A. Notify the physician.
- B. Elevate the head of the bed.
- C. Place the client in the left lateral decubitus position.
- D. Stop the TPN and hang D5 1/2 NS.
Correct Answer: C
Rationale: Air embolism is suspected. Placing the client in the left lateral decubitus position traps air in the right atrium, preventing pulmonary embolism. Notifying the physician (A), elevating the bed (B), or changing fluids (D) is secondary.
Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
- A. Weight gain should be reported to the physician.
- B. An alternate method of birth control is needed when taking antibiotics.
- C. If the client misses one or more pills,two pills should be taken per day for one week.
- D. Changes in the menstrual flow should be reported to the physician.
Correct Answer: B
Rationale: Antibiotics can reduce the effectiveness of oral contraceptives by altering gut flora necessitating an alternate birth control method during antibiotic use. Weight gain and menstrual changes are common and doubling pills is not the correct protocol for missed doses.
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. Immediate treatment of mild PIH includes the administration of a variety of medications
- B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
- C. Self-discipline is required to control caloric intake throughout the pregnancy
- D. The client may not recognize the early symptoms of PIH
Correct Answer: D
Rationale: Mild PIH is not treated with medications. Emotional stress is not the cause of blood pressure elevation in PIH. Excessive caloric intake is not the cause of weight gain in PIH. The client most frequently is not aware of the signs and symptoms in mild PIH.
The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?
- A. Mother is concerned about her recovery.
- B. Mother calls infant by name.
- C. Mother lightly touches infant.
- D. Mother is concerned about her weight gain.
Correct Answer: B
Rationale: In the taking-hold phase, the mother actively engages with the infant, such as calling the infant by name, indicating bonding.