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A client with chronic renal failure is prescribed erythropoietin (Epogen). Which outcome indicates that the medication is effective?
- A. Increased urine output.
- B. Improved hemoglobin levels.
- C. Decreased blood pressure.
- D. Stable potassium levels.
Correct Answer: B
Rationale: The correct answer is B: Improved hemoglobin levels. Erythropoietin stimulates the production of red blood cells, leading to an increase in hemoglobin levels. This is the desired outcome in a client with chronic renal failure, as it helps alleviate anemia.
Choice A is incorrect because increased urine output is not a direct indicator of erythropoietin effectiveness. Choice C is incorrect as erythropoietin does not directly impact blood pressure. Choice D is incorrect because stable potassium levels are not a primary outcome of erythropoietin therapy in chronic renal failure.
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The client with bacterial pneumonia is receiving intravenous antibiotics. Which assessment finding indicates that the treatment is effective?
- A. Increased respiratory rate.
- B. Decreased oxygen saturation.
- C. Clear lung sounds.
- D. Elevated white blood cell count.
Correct Answer: C
Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate effective treatment as they suggest improved air exchange and resolution of lung congestion caused by pneumonia. Increased respiratory rate (A) and decreased oxygen saturation (B) are signs of respiratory distress and ineffective treatment. Elevated white blood cell count (D) indicates ongoing infection, not effectiveness of treatment. Therefore, clear lung sounds are the best indicator of treatment effectiveness in bacterial pneumonia.
A client with hypertension is receiving dietary education from a nurse. Which recommendation should the nurse include?
- A. Increase your intake of saturated fats.
- B. Limit your sodium intake to less than 2 grams per day.
- C. Avoid foods high in potassium.
- D. Consume at least three alcoholic beverages daily.
Correct Answer: B
Rationale: The correct answer is B: Limit your sodium intake to less than 2 grams per day. Sodium restriction is crucial in managing hypertension as it helps reduce blood pressure. Excessive sodium intake can lead to fluid retention and increased blood volume, worsening hypertension. This recommendation aligns with evidence-based guidelines for hypertension management.
Incorrect choices:
A: Increasing saturated fat intake is not recommended for hypertension, as it can lead to cardiovascular issues.
C: Avoiding foods high in potassium is not advised, as potassium helps regulate blood pressure.
D: Consuming alcoholic beverages daily can raise blood pressure and interfere with hypertension management.
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.
A healthcare professional is assessing a client with severe dehydration. Which finding indicates a need for immediate intervention?
- A. Heart rate of 110 beats per minute.
- B. Blood pressure of 90/60 mm Hg.
- C. Urine output of 20 ml/hour.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: The correct answer is C: Urine output of 20 ml/hour. In severe dehydration, decreased urine output indicates compromised renal function and impaired fluid balance, necessitating immediate intervention to prevent further complications. A: Heart rate of 110 bpm is elevated but not an immediate concern. B: Blood pressure of 90/60 mm Hg is low but may be compensated in dehydration. D: Dry mucous membranes are a sign of dehydration but not an immediate threat compared to inadequate urine output.
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.