Nokea
A client with end stage renal disease has been managed by peritoneal dialysis. Which finding should be reported to the doctor immediately?
- A. The amount of dialysate return is less than that instilled.
- B. The client complains of abdominal pain and nausea.
- C. The dialysate return is colorless in appearance.
- D. The client has lost two pounds in the last week.
Correct Answer: B
Rationale: Complaints of abdominal pain, nausea, fever, and return of cloudy dialysate should be reported to the physician since they are indications of peritonitis. Diminished or slow return of dialysate, as mentioned in answer A, is managed by having the client turn side to side or move about to facilitate return flow, so it is incorrect. Answers C and D are favorable findings that do not require intervention; therefore, they are incorrect.
You may also like to solve these questions
A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
- A. I cannot give this medication as it is written. I have no idea of what you mean.
- B. Would you please clarify what you have written so I am sure I am reading it correctly?
- C. I am having difficulty reading your handwriting. It would save me time if you would be more careful.
- D. Please print in the future so I do not have to spend extra time attempting to read your writing.
Correct Answer: B
Rationale: Would you please clarify what you have written so I am sure I am reading it correctly? This is respectful and ensures patient safety.
The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group?
- A. Bulimia
- B. Anorexia
- C. Obesity
- D. Malnutrition
Correct Answer: C
Rationale: Obesity. Factors like sedentary lifestyles and poor nutrition knowledge contribute to high obesity rates in school-aged children.
A woman is scheduled for a breast biopsy. She is crying and says, 'I am so upset because I watched my mother die from ovarian cancer.' What is the most appropriate nursing diagnosis?
- A. Fear
- B. Anxiety
- C. Ineffective family coping
- D. Spiritual distress
Correct Answer: A
Rationale: Fear of cancer due to her mother's death is the most specific diagnosis, addressing her emotional response to the biopsy.
A newly diagnosed diabetic is learning to administer her injections of NPH and regular insulin. Which statement indicates that the client understands the nurse's teaching regarding proper insulin administration?
- A. I will administer the NPH and regular insulin in two separate injections.
- B. I will withdraw the dose of regular insulin before withdrawing the NPH insulin.
- C. It does not matter which insulin is withdrawn first as long as the amount is correct.
- D. I will withdraw the dose of NPH insulin before withdrawing the regular insulin.
Correct Answer: B
Rationale: When mixing NPH and regular insulin, regular insulin (clear) should be withdrawn first to avoid contaminating it with NPH (cloudy). Separate injections are not standard. Order matters (C is incorrect). Withdrawing NPH first risks contamination.
A patient with second- and third-degree burns. The client is receiving morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention.
Which of the following actions, if taken by the nurse, is BEST?
- A. Recommend that the morphine dose be decreased.
- B. Withhold the pain medication.
- C. Administer the medication by another route.
- D. Explore alternative pain management techniques.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) could indicate a possible impending ileus, this option is not ideal (2) inappropriate (3) inappropriate (4) correct-morphine is drug of choice for burn pain management; when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important