Nokea
A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?
- A. Document the findings.
- B. Elevate the extremity.
- C. Apply gentle pressure.
- D. Assess the client's temperature.
Correct Answer: A
Rationale: A bruit indicates a patent AV graft, a normal finding that should be documented.
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A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute. Which intervention is most important for the nurse to implement?
- A. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
- B. Medicate for pain and monitor vital signs according to protocol.
- C. Encourage the client to splint the incision with a pillow to cough and deep breathe.
- D. Administer intravenous fluid bolus as prescribed by the healthcare provider.
Correct Answer: A
Rationale: Applying oxygen addresses potential hypoxia or respiratory distress indicated by the elevated vital signs.
A patient with gouty arthritis is experiencing tenderness and swelling in the right ankle and big toe. The nurse notes that the inflammation extends above the ankle area. The patient has been prescribed colchicine and indomethacin. What should the nurse include in the discharge teaching?
- A. Consume high-protein foods to reach an ideal body weight.
- B. Drink at least eight cups (1920 mL) of water each day.
- C. Use an electric heating pad when the pain is severe.
- D. Encourage active range of motion exercises to prevent stiffness.
Correct Answer: B
Rationale: Drinking ample water helps flush uric acid, reducing crystal formation and inflammation in gouty arthritis.
Which group of foods should the nurse recommend for patients with a strong family history of colon and rectal cancers?
- A. Lean beef, salads, and baked potatoes.
- B. Potatoes, low-fat breads, and applesauce.
- C. Oatmeal, raisins, and fruit with skin.
- D. Chicken, rice, and wheat products.
Correct Answer: C
Rationale: Oatmeal, raisins, and fruit with skin are high in fiber, which supports gut health and reduces the risk of colorectal cancer.
A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient's laboratory values should the nurse review?
- A. Blood pH level
- B. Hematocrit
- C. White blood cell (WBC) count
- D. Platelet count
Correct Answer: C
Rationale: WBC count indicates infection, relevant to purulent drainage in a burn wound.
An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The patient reports feeling very weak and jittery. What actions should the nurse take?
- A. Check fingerstick glucose level.
- B. Assess skin temperature and moisture.
- C. Administer a PRN dose of regular insulin.
- D. Document anxiety on the surgical checklist.
- E. Measure pulse and blood pressure.
Correct Answer: A,B,E
Rationale: Checking fingerstick glucose, assessing skin temperature/moisture, and measuring pulse/blood pressure are critical to evaluate for hypoglycemia, a likely cause of weakness and jitteriness in a diabetic patient.