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A client with chronic renal failure is receiving hemodialysis. Which dietary restriction should the nurse emphasize?
- A. Low-protein diet.
- B. High-sodium diet.
- C. Low-potassium diet.
- D. High-calcium diet.
Correct Answer: C
Rationale: A low-potassium diet is critical in chronic renal failure to prevent hyperkalemia, which can cause cardiac complications.
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A client is taking ciprofloxacin (Cipro). Which of the following laboratory studies will not be affected by ciprofloxacin?
- A. Theophylline level.
- B. Prothrombin time (PT).
- C. Partial thromboplastin time (PTT).
- D. Total iron-binding capacity.
Correct Answer: D
Rationale: Ciprofloxacin does not typically affect total iron-binding capacity, unlike theophylline levels (drug interaction) or coagulation studies (PT/PTT).
The nurse is discussing safety and accident prevention with the mother of a 9-month-old. The teaching has been effective when the mother states which of the following?
- A. I make sure that I keep my cleaning supplies locked up.'
- B. Sometimes she plays in the bathroom when I'm cleaning in there.'
- C. Occasionally she gets under the chair and plays with the telephone cord.'
- D. I've found that those child-protective cabinet locks don't work very well.'
Correct Answer: A
Rationale: Keeping cleaning supplies locked up indicates effective teaching on safety, as it prevents the child from accessing hazardous substances.
The nurse teaches a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client has a need for further teaching if the client makes which statement?
- A. An anesthetic throat spray will be used.
- B. A signed informed consent is necessary.
- C. Medication will be given orally for sedation.
- D. It is important to lie still during the procedure.
Correct Answer: C
Rationale: Intravenous sedation (not oral) is given to relax the client, and an anesthetic throat spray is used to help keep the client from gagging as the endoscope is passed. The client has to sign an informed consent form. The client also needs to lie still for ERCP, which takes about an hour to perform.
A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client complains of chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first?
- A. Administer oxygen.
- B. Inspect the client's incision.
- C. Call the rapid response team.
- D. Reposition the ECG electrodes.
Correct Answer: A
Rationale: Chest pain post-myocardial infarction suggests possible cardiac ischemia, so administering oxygen is the priority to improve oxygenation. The other actions follow after initial stabilization.
Which of the following should first alert the nurse that a child is hemorrhaging after a tonsillectomy?
- A. Mouth breathing.
- B. Frequent swallowing.
- C. Requests for a drink.
- D. Increased pulse rate.
Correct Answer: B
Rationale: Frequent swallowing is the earliest sign of post-tonsillectomy hemorrhage, as the child swallows blood from the surgical site. Increased pulse rate may occur later.