Nokea
A client with chronic renal failure is receiving peritoneal dialysis. The nurse should assess the client for which of the following complications?
- A. Hypertension
- B. Hyperglycemia
- C. Hypokalemia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperglycemia. In peritoneal dialysis, hyperglycemia can occur due to the glucose content of the dialysate solution. This high glucose concentration can lead to increased blood sugar levels in the client. Option A, Hypertension, is a common complication in chronic renal failure but is not directly related to peritoneal dialysis. Option C, Hypokalemia, is more commonly associated with loop diuretics or inadequate potassium intake. Option D, Hypernatremia, is more often seen in conditions of excessive sodium intake or water loss, rather than in peritoneal dialysis.
You may also like to solve these questions
A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is
- A. Central nervous system damage
- B. Moderate anemia
- C. Renal tubule damage
- D. Growth impairment
Correct Answer: A
Rationale: Corrected Rationale: Chronic lead poisoning can lead to severe and irreversible damage to the central nervous system, including cognitive and developmental delays. Central nervous system damage is the most serious effect of chronic lead poisoning because it can have long-lasting consequences on a child's cognitive function and overall development. Moderate anemia (Choice B), renal tubule damage (Choice C), and growth impairment (Choice D) can also occur due to lead poisoning, but they are not as severe or potentially irreversible as the damage to the central nervous system.
Iwa, two years old, was brought to the health center because of diarrhea for 4 days. Assessment revealed that Iwa has under-nutrition. Which of the following actions will you take?
- A. Advise the mother to give milk and juices between meals at home
- B. Give nutritious food available at home
- C. Refer to the hospital for proper management
- D. Provide mother with ORS solution and show her how to give the solution
Correct Answer: A
Rationale: In the case of a child with under-nutrition and diarrhea, advising the mother to give milk and juices between meals at home is the appropriate action. This helps address the nutritional needs of the child while also providing hydration. Option B, giving nutritious food available at home, may not be sufficient in addressing immediate needs such as dehydration. Option C, referring to the hospital, may be necessary in severe cases but is not the first-line action. Option D, providing ORS solution, is important but does not directly address the under-nutrition concern.
During a visit to the community health clinic, a 45-year-old Native American female, who has a BMI of 35, complains of changes in her vision. Which condition is most important for the RN to be aware of in the client's family history?
- A. Diabetes
- B. Glaucoma
- C. Hypertension
- D. Brain Tumor
Correct Answer: A
Rationale: The correct answer is A: Diabetes. Given the client's Native American ethnicity, high BMI, and vision changes, diabetes is the most crucial condition for the nurse to be aware of in the client's family history. Diabetes is strongly associated with vision problems, especially diabetic retinopathy. Glaucoma (choice B) is a condition that affects the optic nerve and can lead to vision loss but is not as directly linked to the client's BMI and ethnic background. Hypertension (choice C) can also impact vision, but in this case, diabetes takes precedence based on the client's profile. Brain tumor (choice D) is less likely to be related to the client's BMI, ethnicity, and vision changes compared to diabetes.
In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test?
- A. Increased edema and weight gain
- B. Unchanged urine specific gravity
- C. Rapid protein excretion
- D. Decreased blood potassium
Correct Answer: B
Rationale: After a water deprivation test in a client suspected of having diabetes insipidus, the nurse would expect the urine specific gravity to remain unchanged. This occurs because in diabetes insipidus, the kidneys are unable to concentrate urine, leading to a low urine specific gravity even after water deprivation. Choices A, C, and D are incorrect. Increased edema and weight gain are not typical findings in diabetes insipidus. Rapid protein excretion is not directly related to the condition, and decreased blood potassium is not a common outcome of a water deprivation test for diabetes insipidus.
A 67-year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infarction (MI). The priority nursing diagnosis for this client during the immediate 24 hours is
- A. Constipation related to immobility
- B. High risk for infection
- C. Impaired gas exchange
- D. Fluid volume deficit
Correct Answer: C
Rationale: The correct answer is C: Impaired gas exchange. In a client with an acute myocardial infarction, impaired gas exchange is a priority nursing diagnosis due to compromised heart function, which affects oxygenated blood circulation. Close monitoring and interventions are crucial to ensure adequate oxygenation. Choices A, B, and D are incorrect: A) Constipation related to immobility is not the priority in this acute situation; B) High risk for infection is not the immediate concern related to the client's primary diagnosis; D) Fluid volume deficit, while important, is not the priority compared to addressing impaired gas exchange in acute MI.