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A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?
- A. Weight gain of 1 kg since the last dialysis session
- B. Blood pressure of 150/90 mm Hg
- C. Potassium level of 6.5 mEq/L
- D. Hemoglobin level of 10 g/dL
Correct Answer: C
Rationale: The correct answer is C: Potassium level of 6.5 mEq/L. High potassium levels in ESRD patients can lead to life-threatening cardiac arrhythmias. Immediate action is needed to prevent complications. A: Weight gain may indicate fluid retention, but it's not an immediate concern. B: Blood pressure is elevated but not an urgent issue. D: Hemoglobin level of 10 g/dL is within the acceptable range for ESRD patients and does not require immediate action.
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When determining hearing acuity, if the client reports first perceiving sound at ___ dB, then his or her hearing is normal.
- A. 4
- B. 8
- C. 12
- D. 16
Correct Answer: A
Rationale: Normal hearing acuity is typically defined as perceiving sound at 0-25 dB. Therefore, 4 dB would be within the range of normal hearing.
You are working in a community health clinic and a client needs instructions for care of a hordeolum (sty) to the right upper eyelid. What is the first treatment that the client should try?
- A. Apply warm compresses 4 times/day.
- B. Gently perform hygienic eyelid scrubs.
- C. Obtain prescription for antibiotic drops.
- D. Contact the ophthalmologist.
Correct Answer: A
Rationale: Warm compresses are the first-line treatment for a hordeolum, as they promote drainage and reduce inflammation.
A client with Parkinson's disease is prescribed carbidopa-levodopa (Sinemet). What should the nurse include in the teaching about this medication?
- A. Take the medication without a high-protein meal.
- B. Expect the medication to take several weeks to reach full effectiveness.
- C. The medication may cause urine to turn light.
- D. You may experience a rapid heartbeat as a common side effect.
Correct Answer: B
Rationale: The correct answer is B: Expect the medication to take several weeks to reach full effectiveness. This is because carbidopa-levodopa (Sinemet) is a medication used to treat Parkinson's disease by increasing dopamine levels in the brain. It takes time for the medication to build up in the system and reach its full therapeutic effect.
Choice A is incorrect because it is recommended to take carbidopa-levodopa with a high-protein meal to help reduce potential gastrointestinal side effects. Choice C is incorrect as the medication does not typically cause urine discoloration. Choice D is incorrect as a rapid heartbeat is not a common side effect of carbidopa-levodopa.
In summary, choice B is correct because it aligns with the pharmacokinetics of the medication, while the other choices are not consistent with the usual effects and recommendations for carbidopa-levodopa.
A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?
- A. Average daily fluid intake
- B. Neck circumference
- C. Height & weight
- D. Occupation & hobbies
Correct Answer: D
Rationale: The correct answer is D: Occupation & hobbies. This information is crucial as certain occupations or hobbies may expose the client to respiratory hazards, influencing their respiratory status. The healthcare professional needs to assess potential respiratory risks in the client's environment.
A: Average daily fluid intake is important for overall health but not directly related to respiratory status assessment.
B: Neck circumference is more relevant for assessing risk of obstructive sleep apnea rather than overall respiratory status.
C: Height & weight are important for assessing overall health and potential respiratory issues like obesity, but not as immediate as assessing respiratory hazards in the client's daily activities.
A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?
- A. Monitoring urine output
- B. Checking blood glucose levels
- C. Assessing for chest pain
- D. Monitoring electrolyte levels
Correct Answer: C
Rationale: The correct answer is C: Assessing for chest pain. The priority assessment for a client post-MI is to monitor for any signs of recurrent chest pain or angina, as it could indicate ongoing cardiac ischemia or a new infarction. Prompt intervention is crucial in these situations to prevent further damage to the heart muscle. Monitoring urine output (A) and electrolyte levels (D) are important assessments but do not take precedence over assessing for chest pain. Checking blood glucose levels (B) is relevant for diabetic clients but is not the priority in this case.