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A client with chronic kidney disease (CKD) is scheduled for a renal biopsy. Which pre-procedure instruction should the nurse provide?
- A. Maintain a low-protein diet for 24 hours before the biopsy.
- B. Avoid taking anticoagulant medications for one week before the biopsy.
- C. Drink plenty of fluids before the procedure.
- D. Take your routine medications with a full glass of water before the biopsy.
Correct Answer: B
Rationale: The correct answer is B: Avoid taking anticoagulant medications for one week before the biopsy. This is essential to prevent excessive bleeding during and after the procedure. Chronic kidney disease patients are at higher risk of bleeding due to impaired kidney function.
A: Maintaining a low-protein diet is not directly related to the biopsy procedure and is not necessary.
C: Drinking plenty of fluids may be beneficial for renal function but is not a specific pre-procedure instruction for a renal biopsy.
D: Taking routine medications with water is important, but specific instructions regarding anticoagulant medications are more critical in this case.
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During the initial assessment of a client with a history of substance abuse admitted for detoxification, which intervention is most important?
- A. Obtain a detailed substance use history.
- B. Establish a trusting nurse-client relationship.
- C. Evaluate the client's physical health status.
- D. Determine the client's readiness for change.
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's physical health status. This is crucial during detoxification as substance withdrawal can lead to serious physical health complications such as seizures or cardiac issues. Assessing physical health status allows for prompt intervention if needed. Obtaining a detailed substance use history (A) can provide valuable information but is not immediate priority during initial assessment. Establishing a trusting nurse-client relationship (B) is important but ensuring physical safety comes first. Determining client's readiness for change (D) is important for long-term treatment planning but not as urgent as assessing physical health status.
A client with chronic kidney disease is prescribed a low-protein diet. Which laboratory result should the nurse monitor to evaluate the effectiveness of the diet?
- A. Blood urea nitrogen (BUN)
- B. Serum potassium
- C. Serum calcium
- D. Creatinine clearance
Correct Answer: A
Rationale: The correct answer is A: Blood urea nitrogen (BUN). BUN is a waste product that reflects protein intake and kidney function. In chronic kidney disease, high protein intake can increase BUN levels, so monitoring BUN helps assess the effectiveness of the low-protein diet.
Incorrect choices:
B: Serum potassium - This is more related to kidney function but not specifically affected by a low-protein diet.
C: Serum calcium - Calcium levels are not directly affected by protein intake or a low-protein diet in chronic kidney disease.
D: Creatinine clearance - This measures kidney function but is not directly influenced by protein intake.
A client with hyperthyroidism is prescribed propylthiouracil (PTU). Which instruction should the nurse include in the client's discharge teaching?
- A. Report any signs of infection, such as sore throat or fever, to your healthcare provider.'
- B. Increase your intake of iodine-rich foods, such as seafood and dairy products.'
- C. Take the medication on an empty stomach for better absorption.'
- D. You may experience weight gain and fatigue as side effects of the medication.'
Correct Answer: A
Rationale: The correct answer is A: "Report any signs of infection, such as sore throat or fever, to your healthcare provider." This is important because PTU can cause agranulocytosis, a serious side effect that can lead to severe infections. By reporting signs of infection early, the healthcare provider can monitor the client's blood counts and adjust treatment if necessary.
Choice B is incorrect because increasing intake of iodine-rich foods can worsen hyperthyroidism. Choice C is incorrect because PTU should be taken with food to minimize gastrointestinal side effects. Choice D is incorrect because weight gain and fatigue are not common side effects of PTU; in fact, weight loss and hyperactivity are more common.
An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?
- A. This behavior can be considered sexual harassment and should be reported to the administration immediately.
- B. The UAP should be reassigned to another group of residents, preferably females only.
- C. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need.
- D. The resident needs to understand the rules regarding unwanted touching of the staff and the consequences.
Correct Answer: C
Rationale: The correct answer is C because the behavior exhibited by the resident may stem from touch deprivation rather than being intentional sexual harassment. Here's a step-by-step rationale:
1. Understanding the resident's age and environment (extended care facility) helps in interpreting his behavior.
2. The resident's actions suggest a need for touch, which is common in older adults who may lack physical contact.
3. Educating the resident on appropriate ways to express his need for touch can address the underlying issue.
4. Reassigning the UAP or reporting the incident as sexual harassment (options A and B) may not address the root cause of the behavior and could potentially harm the resident's well-being.
In summary, choice C focuses on addressing the resident's potential touch deprivation in a compassionate and understanding manner, making it the best assessment of the situation.
The client has a nasogastric (NG) tube and is receiving enteral feedings. What intervention should the nurse implement to prevent complications associated with the NG tube?
- A. Flush the NG tube with water before and after feedings.
- B. Check gastric residual volume every 6 hours.
- C. Keep the head of the bed elevated at 30 degrees.
- D. Replace the NG tube every 24 hours.
Correct Answer: C
Rationale: Correct Answer: C - Keep the head of the bed elevated at 30 degrees.
Rationale:
1. Elevating the head of the bed at 30 degrees helps prevent aspiration by promoting proper drainage of gastric contents.
2. This position reduces the risk of reflux and pulmonary complications in clients with NG tubes.
3. It also helps maintain the proper position of the tube in the stomach, decreasing the likelihood of displacement.
Summary of Other Choices:
A. Flushing the NG tube with water before and after feedings is important for tube patency but does not directly prevent complications associated with the NG tube.
B. Checking gastric residual volume every 6 hours is important to monitor feeding tolerance but does not directly prevent complications related to the NG tube.
D. Replacing the NG tube every 24 hours is not necessary unless there are specific indications such as tube blockage or dislodgment. Regular replacement can increase the risk of complications and is not a standard practice.