Nokea
A client with advanced chronic kidney disease (CKD) is scheduled for hemodialysis. Which dietary instruction should the nurse provide to the client?
- A. Limit fluid intake to prevent fluid overload
- B. Increase sodium intake to improve fluid balance
- C. Increase potassium intake to prevent hypokalemia
- D. Increase protein intake to promote healing
Correct Answer: A
Rationale: The correct answer is A: 'Limit fluid intake to prevent fluid overload.' Clients with advanced chronic kidney disease are at risk of fluid retention, which can lead to complications like fluid overload and hypertension. Therefore, it is crucial to instruct the client to limit fluid intake. Choice B is incorrect because increasing sodium intake can exacerbate fluid retention and hypertension in clients with CKD. Choice C is incorrect as increasing potassium intake can be dangerous for clients with CKD who may already have elevated potassium levels. Choice D is incorrect because while protein intake may need to be adjusted for clients on hemodialysis, the priority in this case is managing fluid intake.
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A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?
- A. Flaccid paralysis
- B. Pupils fixed and dilated
- C. Diminished spinal reflexes
- D. Reduced sensory responses
Correct Answer: B
Rationale: Fixed, dilated pupils are a sign of increased intracranial pressure or brain injury, indicating a potentially serious neurological condition. Flaccid paralysis, although concerning, may not always indicate immediate life-threatening issues. Diminished spinal reflexes and reduced sensory responses are important neurological assessments but are not as acutely concerning as fixed, dilated pupils in this context.
A client is admitted for first and second-degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be
- A. Cover the areas with dry sterile dressings
- B. Assess for dyspnea or stridor
- C. Initiate intravenous therapy
- D. Administer pain medication
Correct Answer: B
Rationale: Assessing for dyspnea or stridor is crucial as these are signs of airway compromise, which is a priority concern in burns involving the face. Burns on the face can lead to airway swelling or compromise due to airway proximity, making respiratory assessment the top priority. Covering the areas with dry sterile dressings, initiating intravenous therapy, and administering pain medication are important interventions but assessing for airway issues takes precedence in this situation.
The nurse leading a medical-surgical unit care team assigns client care to a PN and a UAP. Which task should the nurse delegate to the UAP?
- A. Assess a client's pain level post-surgery
- B. Turn and reposition a client with a total hip replacement
- C. Administer a dose of insulin per sliding scale
- D. Change a postoperative dressing
Correct Answer: B
Rationale: Turning and repositioning a client is within the scope of practice of a UAP. This task helps prevent pressure ulcers and assists in maintaining the client's comfort and mobility. Assessing pain level post-surgery requires clinical judgment and interpretation, making it appropriate for a PN or RN. Administering medication like insulin involves critical thinking and potential adjustments based on the client's condition, which is the responsibility of a licensed nurse. Changing postoperative dressings involves wound assessment, infection control, and knowledge of aseptic techniques, tasks that fall under the purview of a PN or RN.
A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?
- A. Encourage discussion about feelings of limb loss.
- B. Administer a prescription for gabapentin.
- C. Teach the client how to wrap the stump with an elastic bandage.
- D. Offer assistance to move to a quiet room to relax.
Correct Answer: B
Rationale: The correct answer is B: Administer a prescription for gabapentin. Gabapentin is used to treat phantom limb pain, which is common after amputations. Encouraging discussion about feelings of limb loss (choice A) is important for emotional support but does not address the physical pain. Teaching the client how to wrap the stump with an elastic bandage (choice C) is not indicated for aching in the 'right foot' as described. Offering assistance to move to a quiet room to relax (choice D) may provide comfort but does not address the underlying issue of phantom limb pain.
A client is admitted with a suspected gastrointestinal bleed. What assessment finding requires immediate intervention?
- A. Bright red blood in the vomit.
- B. Elevated blood pressure and heart rate.
- C. Coffee ground emesis.
- D. Dark, tarry stools.
Correct Answer: D
Rationale: Dark, tarry stools indicate the presence of digested blood in the gastrointestinal tract, signifying a higher gastrointestinal bleed. This finding requires immediate intervention due to the potential severity of the bleed. Bright red blood in the vomit may indicate active bleeding but is not as concerning as digested blood. Elevated blood pressure and heart rate are common responses to bleeding but do not provide direct evidence of the source or severity of the bleed. Coffee ground emesis is indicative of partially digested blood and is a concern but not as urgent as dark, tarry stools.