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A nurse is assisting with the care of a client who has hypertension and chronic kidney disease. The client is scheduled for hemodialysis. Which of the following actions should the nurse plan to take while caring for this client? (Select all that apply.)
- A. Obtain the client's weight.
- B. Verify the glomerular filtration rate.
- C. Check the graft site for a palpable thrill.
- D. Document vital signs.
- E. Administer a sedative to the client.
Correct Answer: A,C,D
Rationale: Obtaining the client's weight, checking the graft site for a palpable thrill, and documenting vital signs are essential to monitor fluid balance, ensure vascular access functionality, and detect complications during hemodialysis.
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A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?
- A. Review stress factors that can cause disease exacerbation.
- B. Evaluate fluid and electrolyte levels.
- C. Promote physical mobility.
- D. Provide emotional support.
Correct Answer: B
Rationale: Evaluating fluid and electrolyte levels is the priority due to significant fluid loss and electrolyte imbalances during an acute exacerbation of ulcerative colitis.
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following findings should the nurse expect?
- A. Difficulty starting the flow of urine.
- B. Painful urination.
- C. Urge incontinence.
- D. Critically elevated prostate-specific antigen (PSA) level.
Correct Answer: A
Rationale: Difficulty starting urine flow is common in BPH due to prostate enlargement obstructing the urethra.
A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?
- A. High fever in the early morning.
- B. Fatigue.
- C. Increased appetite.
- D. Night sweats.
Correct Answer: D
Rationale: Night sweats are a classic symptom of pulmonary tuberculosis, resulting from the body's immune response to the infection.
A nurse is reinforcing dietary teaching to a client who is at risk for osteoporosis about increasing her calcium intake. Which of the following foods should the nurse recommend the client consume frequently?
- A. Zucchini.
- B. Collards.
- C. Potatoes.
- D. Carrots.
Correct Answer: B
Rationale: Collards are a good source of calcium, essential for bone health and reducing osteoporosis risk.
A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding?
- A. Increased urine ketones.
- B. Increased urine specific gravity.
- C. Decreased hematocrit.
- D. Decreased urine output.
Correct Answer: B
Rationale: Increased urine specific gravity is expected in fluid volume deficit, indicating concentrated urine due to decreased fluid intake or excessive fluid loss.