Nokea
A client with partial thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Obtain supplies to re-dress the burn area.
- B. Verify the client's signed consent form.
- C. Give a prescribed narcotic analgesic agent.
- D. Perform active range-of-motion exercises.
Correct Answer: C
Rationale: Before transporting the client for whirlpool therapy to debride the burned area, the nurse should give a prescribed narcotic analgesic agent. This intervention is essential to manage pain effectively during the debridement process. Obtaining supplies to re-dress the burn area (Choice A) is important but not as immediate as providing pain relief. Verifying the client's signed consent form (Choice B) is necessary for procedures but does not address the client's immediate pain needs. Performing active range-of-motion exercises (Choice D) is not indicated before whirlpool therapy for debridement of burns and may cause further discomfort to the client.
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The client is scheduled to begin continuous ambulatory peritoneal dialysis (CAPD). Which of the following statements by the client indicates that more teaching is required?
- A. I will need to limit my intake of protein.
- B. I can skip a dialysis session if I feel tired.
- C. I should increase my intake of potassium-rich foods.
- D. I can eat whatever I want, as long as I take my medications.
Correct Answer: B
Rationale: The correct answer is B. Skipping a dialysis session can lead to serious complications as it disrupts the treatment schedule and can result in the accumulation of waste products and fluid in the body. The client must understand the importance of adhering to the prescribed dialysis regimen to maintain optimal health. Choices A, C, and D are incorrect because limiting protein intake, increasing potassium-rich foods, and taking medications do not pose the same risk as skipping dialysis sessions. These aspects are important in the management of peritoneal dialysis but do not outweigh the critical need for regular dialysis sessions to prevent complications.
The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
- A. Presence and activity of bowel sounds
- B. Color and consistency of feces
- C. Eating patterns and dietary intake
- D. Level and amount of physical activity
Correct Answer: C
Rationale: In chronic pancreatitis, managing abdominal pain is crucial, and assessing the client's eating patterns and dietary intake is essential. Dietary modifications can help alleviate symptoms and reduce the workload on the pancreas. Choices A, B, and D are not directly related to pain management in chronic pancreatitis. Bowel sounds, fecal characteristics, and physical activity may provide important information in other conditions but are not the priority in this scenario.
A client with chronic heart failure is being taught by a nurse about the importance of daily weights. Which of the following instructions should the nurse include?
- A. Weigh yourself at the same time every day.
- B. Use the same scale for weighing each time.
- C. Record your weight in a journal or log.
- D. Report any weight gain of more than 2 to 3 pounds in a day.
Correct Answer: D
Rationale: The correct instruction for a client with chronic heart failure is to report any weight gain of more than 2 to 3 pounds in a day. This weight gain may indicate fluid retention, which is a critical sign of worsening heart failure. Weighing at the same time every day and using the same scale for consistency are good practices, but the crucial action is to promptly report significant weight gain, as stated in option D. Recording the weight in a journal or log can be helpful for tracking trends, but immediate reporting of weight gain is essential for timely intervention in heart failure management. Therefore, option D is the most appropriate instruction for this client.
The client with chronic renal failure is being taught about fluid restrictions by the nurse. Which statement by the client indicates a need for further teaching?
- A. I can drink as much water as I want, as long as I limit my salt intake.
- B. I should limit my fluid intake to prevent fluid overload.
- C. I can skip dialysis sessions if I feel tired.
- D. I can eat whatever I want, as long as I take my medications.
Correct Answer: C
Rationale: Choice C is the correct answer because clients with chronic renal failure should not skip dialysis sessions. Skipping dialysis can lead to serious complications and worsen the client's condition. It is crucial for clients to understand the importance of adhering to their dialysis schedule for optimal management of chronic renal failure. Choices A, B, and D are incorrect because they demonstrate understanding of fluid restrictions, the need to limit fluid intake to prevent overload, and the importance of medication compliance, respectively. These statements show appropriate knowledge and do not indicate a need for further teaching.
What is the primary action of insulin in the body?
- A. To lower blood pressure.
- B. To promote the absorption of glucose into cells.
- C. To increase blood glucose levels.
- D. To decrease blood glucose levels.
Correct Answer: B
Rationale: The correct answer is B: To promote the absorption of glucose into cells. Insulin facilitates the uptake of glucose by cells, thereby decreasing blood glucose levels. Choice A is incorrect as insulin does not directly affect blood pressure. Choice C is inaccurate as insulin works to lower, not increase, blood glucose levels. Choice D is incorrect because insulin's primary role is to lower, not increase, blood glucose levels by promoting glucose uptake into cells.