Nokea
A client with a history of chronic kidney disease is prescribed sevelamer (Renagel). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Take the medication on an empty stomach.
- C. Avoid taking the medication with calcium supplements.
- D. Stop the medication if constipation occurs.
Correct Answer: A
Rationale: Sevelamer should be taken with meals to bind phosphate in the gut.
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A client who voluntarily admitted herself to the mental health hospital adamantly demands to be discharged immediately. What is the most appropriate response by the nurse?
- A. We hate to see you go, but that is your right. I'll get the forms for you so you can go.'
- B. I'm sorry, but your lawyer or family must request such forms when you are hospitalized.'
- C. I will get the forms, but your psychiatrist will need to see you before you leave.'
- D. Are you sure we can't convince you to stay here in a few days? You'll return to a full valid and there are several issues we need to address.'
Correct Answer: C
Rationale: For voluntary admissions, clients can request discharge, but a psychiatric evaluation is typically required to ensure safety. This response ensures protocol is followed while addressing the client's request.
The nurse is assessing a client with a suspected spinal cord injury. Which of the following findings is most indicative of this condition?
- A. Loss of sensation below the injury site.
- B. Increased muscle tone in the arms.
- C. Normal bowel and bladder function.
- D. Absence of pain at the injury site.
Correct Answer: A
Rationale: Loss of sensation below the injury site is a hallmark sign of spinal cord injury due to disrupted nerve pathways.
A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, 'My boyfriend has been beating me up once in a while since I became pregnant'”but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children.' Which of the following actions should be the priority by the nurse at this time?
- A. Contact a social worker for assistance and family counseling.
- B. Help the client make concrete plans for the safety of herself and her children.
- C. Tell the client and how anyone to hit her or her children.
- D. Provide the client with brochures on the statistics about violence against women.
Correct Answer: B
Rationale: Prioritizing safety planning protects the client and her children from further abuse.
The nurse is caring for a client with a history of peripheral artery disease. Which of the following interventions is most appropriate?
- A. Keep the legs elevated above heart level.
- B. Encourage prolonged standing.
- C. Apply warm compresses to the legs.
- D. Promote regular walking.
Correct Answer: D
Rationale: Regular walking promotes collateral circulation in peripheral artery disease, improving blood flow.
A client with a history of cirrhosis is admitted with hepatic encephalopathy. The nurse should include which of the following in the plan of care?
- A. Administer lactulose as prescribed.
- B. Encourage a high-protein diet.
- C. Restrict fluid intake.
- D. Administer sedatives for agitation.
Correct Answer: A
Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy.