Nokea
A nurse is caring for a client who has chronic kidney disease and reports nausea. The nurse should identify that this client is at risk for which of the following imbalances?
- A. Metabolic alkalosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: The correct answer is B: Metabolic acidosis. Clients with chronic kidney disease are at risk for metabolic acidosis because the kidneys are unable to effectively excrete acids, leading to an accumulation of acid in the body. This metabolic imbalance can result in symptoms like nausea. Choices A, C, and D are incorrect. Metabolic alkalosis is not typically associated with chronic kidney disease. Respiratory alkalosis is more commonly seen in conditions such as hyperventilation. Respiratory acidosis, on the other hand, is often linked to conditions affecting the lungs or respiratory system, not primarily kidney disease.
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A nurse is caring for a client who has severe hypertension and is receiving nitroprusside. What action should the nurse take?
- A. Administer oxygen and assess the client's response.
- B. Monitor blood pressure every 2 hours.
- C. Limit light exposure to the IV infusion.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct action for the nurse to take when caring for a client receiving nitroprusside for severe hypertension is to limit light exposure to the IV infusion. Nitroprusside is light-sensitive, and exposure to light can lead to degradation of the medication, reducing its effectiveness. Administering oxygen (Choice A) may be necessary for some clients but is not directly related to the administration of nitroprusside. Monitoring blood pressure every 2 hours (Choice B) is a general nursing intervention for clients with hypertension but does not specifically address the administration of nitroprusside. Attaching an inline filter to the IV tubing (Choice D) is not necessary to address the specific concern of light exposure related to nitroprusside administration.
A client is being discharged with a new prescription for metoprolol. Which of the following instructions should the nurse include?
- A. Do not discontinue this medication suddenly.
- B. Take this medication in the evening to decrease the risk of falls.
- C. Monitor your heart rate before taking this medication.
- D. Avoid grapefruit juice while taking this medication.
Correct Answer: C
Rationale: The correct instruction for a client prescribed metoprolol is to monitor their heart rate before taking the medication. Metoprolol is a beta-blocker that can cause bradycardia (slow heart rate), so it is essential for clients to check their heart rate before each dose. Choice A is incorrect because abruptly stopping metoprolol can lead to adverse effects, so it should not be discontinued suddenly. Choice B is incorrect because there is no specific recommendation to take metoprolol at night to reduce falls. Choice D is incorrect because grapefruit juice can interact with metoprolol, affecting its absorption, and should be avoided.
A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?
- A. Increased oxygen saturation with exercise.
- B. Pursed-lip breathing with exertion.
- C. Productive cough with clear sputum.
- D. Clubbing of the fingers.
Correct Answer: C
Rationale: The correct answer is C: 'Productive cough with clear sputum.' Clients with COPD often have a chronic productive cough with thick, often purulent sputum. This sputum can be white, yellow, green, or clear. Choices A, B, and D are incorrect. Oxygen saturation may decrease with exertion in COPD due to impaired gas exchange. Pursed-lip breathing is used to control dyspnea, not directly related to increased saturation with exercise. Clubbing of the fingers is typically seen in conditions such as cyanotic heart disease or lung cancer.
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching?
- A. Share personal opinions to help influence the group's values.
- B. Measure the accomplishments of the group against a previous group.
- C. Yield in situations of conflicts to maintain group harmony.
- D. Use modeling to help the clients improve their interpersonal skills.
Correct Answer: D
Rationale: The correct answer is D: 'Use modeling to help the clients improve their interpersonal skills.' Modeling is an effective therapeutic technique where the leader demonstrates appropriate behaviors for the group to learn from. This technique can help clients improve their interpersonal skills by observing and replicating positive behaviors. Choices A, B, and C are incorrect. Sharing personal opinions to influence the group's values may not be appropriate as it could hinder the group dynamics and individual autonomy. Comparing accomplishments against a previous group is not a recommended technique as each group is unique, and comparisons may not be beneficial. Yielding in conflicts to maintain group harmony may lead to unresolved issues and hinder the group's progress.
A nurse is caring for a client who is 1 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take?
- A. Irrigate the catheter with 0.9% sodium chloride.
- B. Reposition the catheter.
- C. Notify the provider.
- D. Increase the rate of the continuous bladder irrigation.
Correct Answer: A
Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride to help relieve any obstruction and ensure proper urinary drainage following a TURP. Repositioning the catheter may not address the underlying issue of obstruction. Notifying the provider should be done after attempting to resolve the drainage issue. Increasing the rate of continuous bladder irrigation is not the initial intervention for a catheter that is not draining.