Nokea
A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding is most concerning?
- A. Bradycardia
- B. Muscle weakness
- C. Peaked T waves on the ECG
- D. Decreased deep tendon reflexes
Correct Answer: C
Rationale: The correct answer is C: Peaked T waves on the ECG. In hyperkalemia, elevated potassium levels can affect the heart's electrical activity, leading to changes on the ECG such as peaked T waves. This finding is concerning as it can progress to serious cardiac arrhythmias, including ventricular tachycardia and fibrillation. Bradycardia (choice A) and decreased deep tendon reflexes (choice D) are not typically associated with hyperkalemia. While muscle weakness (choice B) can occur in hyperkalemia due to its effect on neuromuscular function, the most concerning assessment finding indicating the need for immediate intervention in this scenario is peaked T waves on the ECG.
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After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?
- A. Bruises on arms and legs
- B. Round and tight abdomen
- C. Pitting edema in lower legs
- D. Capillary refill of 8 seconds
Correct Answer: D
Rationale: In this situation, the client's capillary refill of 8 seconds is the assessment finding that warrants immediate intervention by the nurse. A capillary refill greater than 3 to 5 seconds indicates poor perfusion, which could be a sign of inadequate circulation and oxygenation. Checking capillary refill is a quick and useful way to assess peripheral perfusion. Bruises on arms and legs may indicate a bleeding disorder but are not as urgent as addressing poor perfusion. A round and tight abdomen could suggest ascites, which is already known in this case. Pitting edema in lower legs is a common finding in malnutrition and ascites but does not require immediate intervention as poor capillary refill does.
The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be monitored closely?
- A. Serum potassium
- B. Hemoglobin
- C. Serum sodium
- D. White blood cell count
Correct Answer: A
Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is undergoing erythropoietin therapy, monitoring serum potassium levels is crucial. Erythropoietin can stimulate red blood cell production, which may lead to an increase in potassium levels, predisposing the client to hyperkalemia. Monitoring serum potassium levels helps in early detection of hyperkalemia and appropriate intervention. Choices B, C, and D are incorrect because although hemoglobin, serum sodium, and white blood cell count are important parameters to monitor in various clinical conditions, they are not specifically associated with erythropoietin therapy in chronic kidney disease.
A nurse is teaching a client with type 2 diabetes about the importance of foot care. Which statement by the client indicates a need for further teaching?
- A. I should check my feet every day for cuts or blisters.
- B. I need to moisturize my feet daily, especially between my toes.
- C. I should wear comfortable shoes that fit well.
- D. I should avoid walking barefoot, even indoors.
Correct Answer: B
Rationale: The correct answer is B. Moisturizing between the toes can create a moist environment that fosters fungal infections. Checking the feet daily for cuts or blisters (choice A) is correct in diabetes management to prevent complications. Wearing comfortable shoes that fit well (choice C) and avoiding walking barefoot (choice D) are also essential in preventing foot ulcers and injuries in diabetic patients.
A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effects, he stopped taking the medication 6 days ago. Which finding warrants immediate intervention by the nurse?
- A. Anxiety and restlessness
- B. Increased bowel movements
- C. Abdominal cramping
- D. Fever and chills
Correct Answer: A
Rationale: The correct answer is A: Anxiety and restlessness. Abruptly stopping corticosteroids can cause adrenal insufficiency, leading to symptoms such as anxiety and restlessness. These symptoms indicate a potential serious complication that requires immediate intervention. Increased bowel movements and abdominal cramping are common side effects of ulcerative colitis and may not warrant immediate intervention. Fever and chills are not typically associated with adrenal insufficiency caused by corticosteroid withdrawal.
A 66-year-old woman is retiring and will no longer have health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?
- A. Woman, Infants, and Children program
- B. Medicaid
- C. Medicare
- D. Consolidated Omnibus Budget Reconciliation Act provision
Correct Answer: C
Rationale: The correct answer is C: Medicare. Title XVII of the Social Security Act of 1965 created the Medicare Program to provide medical insurance for individuals who are 65 years or older, disabled, or have permanent kidney failure. Medicare is the appropriate agency to refer a 66-year-old woman who is retiring and losing her employment-based health insurance. Choice A, the Woman, Infants, and Children program, is not suitable for this scenario as it provides assistance for low-income pregnant women, breastfeeding women, and young children. Choice B, Medicaid, is a program that helps individuals with low income and resources cover medical costs, which may not be applicable to this woman's situation. Choice D, the Consolidated Omnibus Budget Reconciliation Act provision, known as COBRA, allows employees to continue their group health insurance coverage after leaving their job but may not be the best option for this woman in this case.