Nokea
A client with acute renal failure has a potassium level of 6.5 mEq/L. The nurse should prepare for:
- A. IV insulin and glucose.
- B. Oral potassium supplements.
- C. Fluid restriction.
- D. Diuretic administration.
Correct Answer: A
Rationale: Insulin and glucose shift potassium into cells, treating hyperkalemia.
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A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should?
- A. Assess the dialysis access for a bruit and thrill.
- B. Insert an indwelling urinary catheter and drain all urine from the bladder.
- C. Ask the client to turn toward the left side.
- D. Warm the solution in the warmer.
Correct Answer: D
Rationale: Warming the dialysis solution prevents discomfort and promotes effective dialysis by relaxing abdominal muscles.
Which of the following exercises should the nurse advise the client to avoid after a lumbar laminectomy?
- A. Knee-to-chest lifts.
- B. Hip tilts.
- C. Sit-ups.
- D. Pelvic tilts.
Correct Answer: C
Rationale: Sit-ups strain the surgical site and should be avoided to prevent injury post-laminectomy.
A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the client complains of abdominal distention. The nurse checks the progress notes in the medical record, as shown below. What is most likely contributing to the client's abdominal distention?
- A. Bowel obstruction
- B. Paralytic ileus
- C. Peritonitis
- D. Wound dehiscence
Correct Answer: B
Rationale: Abdominal distention 2 days post-AAA repair is most likely due to paralytic ileus, a common postoperative complication from bowel manipulation and anesthesia, causing slowed gut motility. Bowel obstruction, peritonitis, or wound dehiscence would present with additional symptoms (e.g., fever, vomiting, or wound disruption).
Health maintenance and promotion activities are especially important for the older adult. Which of the following activities reflects the ability of chance activity for an otherwise healthy older adult?
- A. Drinks 1,500 mL of fluids per day.
- B. Consumes a balanced diet of 1,200 calories per day.
- C. Walks briskly for 10 minutes three times per week.
- D. Sleeps at least 8 hours each night.
Correct Answer: C
Rationale: Brisk walking promotes cardiovascular health and mobility. 1,500 mL fluid may be insufficient, 1,200 calories is too low for most, and 8 hours sleep is not activity-focused.
A nurse is assessing a client with bone cancer pain. Which of the following components of a thorough pain assessment is most significant for this client?
- A. Intensity.
- B. Cause.
- C. Aggravating factors.
- D. Location.
Correct Answer: A
Rationale: Pain intensity is the most significant component in assessing bone cancer pain, as it guides the urgency and type of pain management interventions needed.