Nokea
A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
- A. Chill the dialysate prior to infusion.
- B. Monitor the client for diarrhea.
- C. Weigh the client before and after the treatment.
- D. Use clean gloves when handling dialysate bags.
Correct Answer: C
Rationale: Weighing before and after tracks fluid removal in peritoneal dialysis, assessing treatment effectiveness. Dialysate is warmed, diarrhea isn't a primary concern, and sterile gloves are preferred.
You may also like to solve these questions
A nurse is preparing to perform a blood glucose test. After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?
- A. Allow the site to dry.
- B. Pierce the puncture site quickly.
- C. Squeeze the site gently to obtain a blood droplet.
- D. Cleanse the site with an antiseptic swab.
- E. Apply blood to the test strip.
Correct Answer: D,A,B,C,E
Rationale: The order is: Cleanse with antiseptic (D), allow to dry (A), pierce (B), squeeze for blood (C), and apply to strip (E) for an accurate, sterile sample.
A nurse is reinforcing teaching for a client who was admitted with an exacerbation of COPD. Which of the following should the nurse include in the client teaching?
- A. You should consume small, frequent meals each day.
- B. You should decrease your caloric intake by 200 calories per day.
- C. You should increase your oxygen to 5 liters per minute if you have shortness of breath.
- D. You should discontinue your prednisone when your symptoms improve.
Correct Answer: A
Rationale: Small, frequent meals reduce diaphragm pressure and breathing effort in COPD. Caloric reduction isn't advised, oxygen adjustments need orders, and prednisone requires tapering.
A nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take? (Select all that apply.)
- A. Maintain skin integrity over the blisters
- B. Apply ice to the larger blisters.
- C. Administer ibuprofen for pain.
- D. Run cool water over the affected area.
- E. Allow the affected area to remain open to air.
Correct Answer: A,C,D
Rationale: Preserving blisters (A), giving ibuprofen (C), and using cool water (D) are appropriate. Ice risks further injury, and leaving it open isn't ideal for initial care.
Nurses' Notes
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg Just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Prescription: Open the splint
- A. Open the splint
- B. Obtain a urinalysis
- C. Place the client on NPO status
- D. Place the client's right leg in a dependent position
Correct Answer:
Rationale: Opening the splint relieves pressure in compartment syndrome.
Vital Signs
Today, 0700:
Blood pressure 122/68 mm Hg
Heart rate 99/min
Respiratory rate 20/min
Temperature 36.4° C (97.6° F)
Laboratory Results
Today, 0700:
Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
Hct 44% (42% to 52%)
BUN 19 mg/dL (10 to 20 mg/dL)
Which of the following client findings should the nurse identify as a contraindication to the administration of furosemide? (Client with potassium 3.2 mEq/L)
- A. Potassium level
- B. Blood pressure
- C. Prescription for digoxin
- D. BUN
- E. Client verbal report
- F. Heart rate
- G. Respiratory rate
Correct Answer: A
Rationale: Hypokalemia (3.2 mEq/L) is a contraindication as furosemide can worsen it, risking arrhythmias.