Nokea
A nurse is caring for a client during his first hemodialysis treatment. The client reports a headache, nausea, and is agitated. Which of the following complications should the nurse identify these findings as manifestations of?
- A. Disequilibrium syndrome
- B. Septicemia
- C. Air embolism
- D. Peritonitis
Correct Answer: A
Rationale: These are classic symptoms of disequilibrium syndrome from rapid fluid/electrolyte shifts during initial dialysis.
You may also like to solve these questions
A nurse is assessing a client who has left-sided heart failure. Which of the following clinical manifestations will the nurse expect?
- A. Lower extremity edema
- B. Crackles in lung bases
- C. Jugular vein distention
- D. Ascites
Correct Answer: B
Rationale: Crackles indicate pulmonary congestion characteristic of left-sided heart failure.
A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?
- A. MI only occurs with exertion.
- B. Stable angina can occur for longer than 30 minutes.
- C. Stable angina can be relieved with rest and nitroglycerin.
- D. The pain of an MI lasts less than 15 minutes.
Correct Answer: C
Rationale: Stable angina is usually relieved within 3-5 minutes by rest or nitroglycerin, while MI pain is more prolonged and severe and not relieved by these measures.
A nurse is caring for a client who has a pulmonary embolism and has been on a heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
- A. Both heparin and warfarin work together to dissolve the clots.
- B. Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level.
- C. The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay.
- D. I will call the provider to get a prescription for discontinuing the IV heparin today.
Correct Answer: B
Rationale: Overlap therapy is needed because warfarin has delayed onset (3-5 days) while heparin provides immediate anticoagulation.
The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).
- A. Severe fluid and electrolyte imbalance
- B. Upper abdominal distention
- C. Metabolic acidosis
- D. Projectile vomiting with a fecal odor
- E. Diarrhea or ribbon-like stools
Correct Answer: A,B,D
Rationale: These reflect SBO pathophysiology: proximal distention, fluid loss/vomiting, and metabolic derangements.
A student nurse is reviewing clinical manifestations of chronic kidney disease. Which of the following findings are consistent with this diagnosis? (Select all that apply)
- A. Hypokalemia
- B. Anemia
- C. Hypertension
- D. Crackles in the lungs
- E. Lethargy
- F. Proteinuria
Correct Answer: B,C,E,F
Rationale: These reflect common CKD complications including erythropoietin deficiency, fluid overload, uremia, and glomerular damage.