Nokea
A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula for hemodialysis. Which finding should the nurse report to the healthcare provider immediately?
- A. No bruit or thrill over the AV fistula.
- B. Redness at the site of the AV fistula.
- C. Client's complaint of pain at the AV fistula site.
- D. Swelling of the hand on the side of the AV fistula.
Correct Answer: A
Rationale: The correct answer is A: No bruit or thrill over the AV fistula. A bruit and thrill indicate proper blood flow through the AV fistula, essential for successful hemodialysis. Absence of these sounds can indicate AV fistula malfunction, leading to inadequate dialysis. Redness, pain, and swelling are common complications of AV fistula placement but do not require immediate reporting unless severe or accompanied by other symptoms like fever or pus drainage. Reporting the absence of a bruit or thrill promptly allows for timely intervention to prevent complications and ensure effective dialysis.
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What dietary advice should the nurse provide to help reduce the occurrence of hot flashes in a post-menopausal client?
- A. Increase intake of spicy foods.
- B. Limit caffeine and alcohol consumption.
- C. Consume a high-protein diet.
- D. Eat more dairy products.
Correct Answer: B
Rationale: The correct answer is B: Limit caffeine and alcohol consumption. Hot flashes can be triggered by stimulants like caffeine and alcohol. Limiting intake can help reduce their occurrence. Increasing spicy foods (A) can actually worsen hot flashes. High-protein diets (C) and consuming more dairy products (D) do not have a direct impact on hot flashes.
A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has 'little reason to live.' She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement?
- A. Encourage the client to remove the gun from her possession.
- B. Notify the client's healthcare provider of the availability of the weapon.
- C. Contact a person of the client's choosing to remove the weapon from the home.
- D. Call the local police department and have the weapon removed from the home.
Correct Answer: C
Rationale: The correct answer is C: Contact a person of the client's choosing to remove the weapon from the home. This option respects the client's autonomy and confidentiality while ensuring her safety.
1. Encouraging the client to remove the gun (Option A) may not guarantee immediate action and could potentially escalate the situation.
2. Notifying the client's healthcare provider (Option B) could breach confidentiality and may not result in immediate intervention.
3. Calling the police (Option D) could lead to a loss of trust and may not be necessary if the situation can be handled discreetly by someone the client trusts.
Therefore, option C is the best course of action as it respects the client's autonomy, maintains confidentiality, and ensures prompt removal of the weapon to enhance the client's safety.
A healthcare professional is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate. What state resource is most likely to provide this information?
- A. Disease registry.
- B. Department of Health.
- C. Bureau of Vital Statistics.
- D. Census data.
Correct Answer: C
Rationale: The correct answer is C: Bureau of Vital Statistics. The Bureau of Vital Statistics is responsible for maintaining records on births, deaths, and other vital events in a particular region. Therefore, it is the most likely state resource to provide information on infant death rates. Disease registry (A) typically focuses on specific diseases rather than overall mortality rates. Department of Health (B) may have some data but may not specifically focus on vital statistics. Census data (D) provides population demographics but does not specifically track infant death rates.
The client with a history of heart failure is taking furosemide (Lasix). Which laboratory result should the nurse monitor closely?
- A. Serum sodium.
- B. Serum potassium.
- C. Serum calcium.
- D. Serum magnesium.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Hypokalemia can exacerbate cardiac arrhythmias in patients with heart failure. Monitoring serum potassium levels is crucial to prevent complications.
Incorrect choices:
A: Serum sodium - Furosemide may cause hyponatremia, but it is less critical compared to hypokalemia in a client with heart failure.
C: Serum calcium - Furosemide does not directly affect calcium levels significantly in most cases.
D: Serum magnesium - While furosemide can cause hypomagnesemia, monitoring potassium is more essential in this scenario due to its impact on cardiac function.
A client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the healthcare team implement first?
- A. Notify the healthcare provider of the assessment findings.
- B. Determine if the client received anesthesia during delivery.
- C. Assign a licensed nurse to reassess the client's vital signs.
- D. Obtain a STAT hemoglobin and hematocrit.
Correct Answer: B
Rationale: The correct answer is B because the client delivered a 7-pound infant 12 hours ago and is now experiencing a severe headache, which could indicate postpartum preeclampsia. Checking if the client received anesthesia during delivery is crucial as certain types of anesthesia can increase the risk of postpartum preeclampsia. This step is important to determine if anesthesia is a contributing factor to the client's symptoms.
Option A is incorrect because immediate action is needed to address the client's symptoms related to anesthesia. Option C is incorrect as reassessing vital signs alone may not provide information specific to the client's headache. Option D is incorrect as obtaining a hemoglobin and hematocrit would not directly address the client's headache or potential anesthesia-related issues.