Nokea
A client with type 1 diabetes mellitus, hypertension, and chronic kidney disease is to begin hemodialysis treatment. Which statement should the nurse include in client education?
- A. Prepare for an abdominal catheter.
- B. Continue routine medications.
- C. Expect the insulin dosage to be reduced.
- D. Include potassium-rich foods in the diet.
Correct Answer: C
Rationale: Insulin dosage may need to be reduced during hemodialysis because insulin is removed by the dialyzer and blood glucose levels may drop. This is the correct statement to include in client education.
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Flow sheets
1915
Arrival at emergency department
1920
Vital Signs:
- Temperature: 98.2° F (36.8° C)
- Heart rate: 92 beats/minute
- Respirations: 24 breaths/minute
- Blood pressure: 210/98 mmHg
- Oxygen saturation: 95% on room air
Imaging studies
1935
Head CT scan results:
- No evidence of intracranial hemorrhage
- No evidence of acute disease
Orders
- Obtain CT scan of the head.
- Insert a large bore peripheral IV.
- Start normal saline infusion at 50 mL/hour.
The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.
A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand. Select the interdisciplinary team members who should assist the client in recovery.
- A. Occupational Therapist
- B. Speech Therapist
- C. Case manager
- D. Physical therapist
- E. Chief Nursing Officer
- F. Pharmacy Technician
Correct Answer: A,B,C,D
Rationale: Occupational, speech, and physical therapists address stroke-related impairments in daily activities, communication, and mobility, while a case manager coordinates care and discharge planning.
Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- B. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- C. Report the COVID-19 result to the local health department according to CDC guidelines.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: B
Rationale: Isolating the client from others not wearing proper PPE is the most important action to prevent transmission of COVID-19, given the client's symptoms suggestive of the virus.
A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiological mechanism should the nurse describe in response to this client's question?
- A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
- B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.
- C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
- D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
Correct Answer: B
Rationale: Inadequate numbers of CD4+ T cells impair cellular immunity, making the client susceptible to opportunistic infections like Pneumocystis jiroveci pneumonia due to HIV infection.
The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?
- A. Hepatorenal failure.
- B. Acute pancreatitis.
- C. Surgical site infection.
- D. Biliary duct obstruction.
Correct Answer: B
Rationale: Acute pancreatitis is indicated by fever, upper abdominal pain radiating to the back, vomiting, and elevated amylase and lipase levels, likely triggered by the cholecystectomy.
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
- A. Redness and edema noted at the incision site.
- B. Apical heart rate of 100 to 110 beats/minute.
- C. High-pitched sound heard upon inspiration.
- D. Pain rating of 8 on a scale of 0 to 10.
Correct Answer: C
Rationale: High-pitched sound heard upon inspiration is a sign of stridor, which is a life-threatening emergency that indicates airway obstruction. The nurse should call for help, administer oxygen, and prepare for intubation or tracheostomy.