Nokea
A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. The client's weight increases by 1 kg in 24 hours.
- B. The client's peritoneal effluent is cloudy.
- C. The client's blood pressure is 140/90 mm Hg.
- D. The client's peritoneal effluent is clear and pale yellow.
Correct Answer: B
Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.
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A client is admitted to the hospital with a diagnosis of pneumonia. Which laboratory test result should the nurse monitor to evaluate the client's respiratory function?
- A. Arterial blood gases (ABGs)
- B. Complete blood count (CBC)
- C. Blood glucose levels
- D. Serum electrolyte levels
Correct Answer: A
Rationale: Arterial blood gases (ABGs) are the most appropriate laboratory test to monitor respiratory function in a client with pneumonia. ABGs provide valuable information on oxygenation status, acid-base balance, and how well the lungs are exchanging gases. This information helps in assessing the effectiveness of ventilation and oxygenation, guiding treatment decisions, and evaluating the overall respiratory status of the client.
During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?
- A. Release the suction by opening the vent.
- B. Continue suctioning to remove obstruction.
- C. Increase the pressure.
- D. Suction deeper.
Correct Answer: A
Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.
The client is reviewing the signed operative consent with a nurse, who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement?
- A. Notify the surgical team of the client's confusion
- B. Have the client sign a new surgical consent
- C. Add the correct leg information to the consent form
- D. Inform the surgeon about the client's concern
Correct Answer: D
Rationale: In this scenario, the nurse should inform the surgeon about the client's concern immediately. This is important to ensure that the correct procedure is performed on the intended leg. Communication with the surgeon is crucial to address any discrepancies in the consent form and prevent errors during the surgical procedure. Having the surgeon clarify and correct the consent form is essential to maintain patient safety and uphold the principles of informed consent.
The client with cholecystitis is being instructed on dietary choices. Which meal best meets the dietary needs of this client?
- A. Steak, baked beans, and a salad
- B. Broiled fish, green beans, and an apple
- C. Pork chops, macaroni and cheese, and grapes
- D. Avocado salad, milk, and angel food cake
Correct Answer: B
Rationale: Cholecystitis requires a low-fat diet to reduce stress on the gallbladder. The meal of broiled fish, green beans, and an apple aligns with this dietary recommendation by providing lean protein and low-fat, high-fiber foods that are easier for the body to digest, making it the most suitable choice for a client with cholecystitis.
Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?
- A. Make the client comfortable and allow the client to sleep.
- B. Assess the client's neurologic status.
- C. Notify the surgeon about the comment.
- D. Ask the client's family to co-sign the operative permit.
Correct Answer: B
Rationale: The nurse should assess the client's neurologic status next. The client's statement about aliens and subsequent falling asleep could be indicative of a potential neurological issue such as confusion or altered mental status. It is essential to assess the client's neurological status to determine the underlying cause of the client's statement and behavior. This assessment will help the nurse identify any potential cognitive impairment or neurological deficits that may need immediate attention, ensuring the client's safety and well-being. Notifying the surgeon or involving the client's family can be considered later, but the priority is to assess the client's neurologic status to address any immediate concerns.