Nokea
A client with acute renal failure reports shortness of breath. The nurse should:
- A. Administer oxygen.
- B. Increase fluid intake.
- C. Check lung sounds.
- D. Encourage coughing.
Correct Answer: C
Rationale: Shortness of breath may indicate fluid overload; lung sounds assess for pulmonary edema.
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A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes diaphoretic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for:
- A. An air embolus.
- B. A pneumothorax.
- C. A pulmonary embolus.
- D. A myocardial infarction.
Correct Answer: B
Rationale: Absent breath sounds, chest pain, and tachycardia post-catheter insertion suggest a pneumothorax, a known complication of subclavian catheter placement, requiring urgent assessment.
A client on hemodialysis reports fatigue. The nurse should assess for:
- A. Anemia.
- B. Hyperkalemia.
- C. Dehydration.
- D. Infection.
Correct Answer: A
Rationale: Anemia is common in renal failure due to decreased erythropoietin.
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
- A. Count the rate to be sure that ventilations are deep enough to be sufficient.
- B. Notify the physician of the client's breathing pattern.
- C. Increase the rate of ventilations.
- D. Increase the tidal volume on the ventilator.
Correct Answer: B
Rationale: Cluster breathing, a sign of neurological deterioration, requires immediate physician notification for evaluation and possible intervention. Adjusting ventilator settings without medical orders is inappropriate, and simply counting the rate does not address the underlying issue.
Which statement by a client with acute renal failure indicates understanding of dietary restrictions?
- A. I will avoid oranges.
- B. I can eat unlimited protein.
- C. I should drink less water.
- D. I will eat more spinach.
Correct Answer: A
Rationale: Oranges are high in potassium, which should be avoided in acute renal failure.
The nurse is assessing a client with a recent history of an above-the-knee amputation presenting with phantom limb pain. The nurse anticipates a prescription for
- A. aripiprazole
- B. oxycodone
- C. amitriptyline
- D. hydroxyzine
Correct Answer: C
Rationale: Amitriptyline, a tricyclic antidepressant, is commonly used for neuropathic pain, including phantom limb pain, due to its effects on nerve signaling.