Nokea
A client with a history of chronic renal failure is receiving hemodialysis. Which assessment finding indicates a complication during dialysis?
- A. Mild fatigue
- B. Hypotension
- C. Slight headache
- D. Stable weight
Correct Answer: B
Rationale: Hypotension during dialysis suggests fluid removal too rapid or disequilibrium syndrome, a serious complication. Fatigue (A), headache (C), and stable weight (D) are less concerning.
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The nurse is caring for a client with a history of a fractured humerus who is in a sling. The client complains of numbness. The nurse should:
- A. Apply ice to the arm
- B. Elevate the arm
- C. Notify the physician immediately
- D. Massage the arm
Correct Answer: C
Rationale: Numbness in a slung humerus suggests neurovascular compromise, requiring immediate physician notification. Ice, elevation, and massage are insufficient or contraindicated.
The physician has ordered a low-sodium diet for a client with hypertension. Which food should the nurse instruct the client to avoid?
- A. Fresh fruit
- B. Grilled chicken
- C. Canned soup
- D. Brown rice
Correct Answer: C
Rationale: Canned soups are high in sodium, which exacerbates hypertension. Fresh fruit, grilled chicken, and brown rice are low-sodium options suitable for a hypertension diet.
The predominant purpose of the first Apgar scoring of a newborn is to:
- A. Determine gross abnormal motor function
- B. Obtain a baseline for comparison with the infant's future adaptation to the environment
- C. Evaluate the infant's vital functions
- D. Determine the extent of congenital malformations
Correct Answer: C
Rationale: Apgar scores are not related to the infant's care, but to the infant's physical condition. Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. Congenital malformations are not one of the areas assessed with Apgar scores.
Which medication does the nurse expect to be ordered for the postpartal patient with bleeding uncontrolled by Pitocin (oxytocin)?
- A. Methergine (methylergonovine maleate)
- B. Aquamephyton (phytonadione)
- C. Amicar (aminocaproic acid)
- D. Celestone (betamethasone)
Correct Answer: A
Rationale: Methergine is used to treat postpartum hemorrhage unresponsive to Pitocin by promoting uterine contractions. Aquamephyton is for clotting, Amicar is for fibrinolysis, and Celestone is a corticosteroid, none of which address uterine bleeding.
The physician has ordered Eskalith (lithium carbonate) 500 mg three times a day and Risperdal (risperidone) 2 mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is:
- A. The client's symptoms of acute mania are typical of undiagnosed schizophrenia.
- B. Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.
- C. The client will be more compliant with a medication that allows some feelings of hypomania.
- D. Antipsychotic medication prevents psychotic symptoms commonly associated with the use of mood stabilizers.
Correct Answer: B
Rationale: Risperidone, an antipsychotic, is used to control acute manic symptoms like agitation, while lithium stabilizes mood over time, addressing the immediate behavioral excitement.