Nokea
A client with cirrhosis is admitted with ascites. The nurse should monitor the client for which of the following complications?
- A. Respiratory distress.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: A
Rationale: Ascites can cause diaphragmatic compression, leading to respiratory distress, which requires monitoring.
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The nurse is assessing a client with a suspected urinary tract infection. Which of the following symptoms is most likely to be present?
- A. Flank pain.
- B. Hypotension.
- C. Bradycardia.
- D. Dry skin.
Correct Answer: A
Rationale: Flank pain is a common symptom of a urinary tract infection, especially if it involves the kidneys.
During your system specific assessment of your client's peripheral pulses, you note that the client's posterior tibia pulse is weak and thready. You would document this finding as:
- A. The client's posterior tibia pulse is Grade B
- B. The client's posterior tibia pulse is Grade C
- C. The client's posterior tibia pulse is 1
- D. The client's posterior tibia pulse is 2
Correct Answer: C
Rationale: A weak and thready pulse is documented as 1+ on a 0-4+ scale, indicating diminished pulse strength.
A client has been scheduled for a barium swallow (esophagography). The nurse determines that the client understands preprocedure instructions when the client states the intention to take which action before the test?
- A. Take all oral medications as scheduled.
- B. Eat a regular breakfast on the day of the test.
- C. Monitor own bowel movement pattern for constipation.
- D. Remove metal objects and jewelry, especially from the neck and chest area.
Correct Answer: D
Rationale: A barium swallow, or esophagography, is a radiograph that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove metal objects such as medals and jewelry before the test so that they will not interfere with radiographic visualization of the field. Some oral medications are withheld before the test, and the client should follow the primary health care provider's instructions regarding medication administration. The client should fast for a minimum of 8 hours before the test, depending on primary health care provider's instructions. It is important after the procedure to monitor for constipation, which can occur as a result of the presence of barium in the GI tract.
A client has received electroconvulsive therapy (ECT). What intervention should the nurse perform first in the posttreatment area and upon the client's awakening?
- A. Assist the client from the stretcher to a wheelchair.
- B. Orient the client and monitor his or her vital signs.
- C. Offer the client frequent reassurance and repeat orientation statements.
- D. Assess for a gag reflex so that the client can eat and drink with safety.
Correct Answer: B
Rationale: The nurse should first monitor vital signs, orient the client, and review with the client that he or she just received an ECT treatment. The posttreatment area should include accessibility to the anesthesia staff, oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment. The nursing interventions outlined in the remaining options will follow accordingly.
The nurse is evaluating the client's potential for development of a pressure sore. Which of the following individual characteristics would be the best indicator of risk for the client's developing a pressure sore?
- A. The client's nutritional status.
- B. The client's circulatory status.
- C. The client's mobility status.
- D. The client's orientation status.
Correct Answer: C
Rationale: Immobility is the primary risk factor for pressure sores, as it leads to prolonged pressure on tissues.