Nokea
A nurse is caring for a client with an indwelling urinary catheter. Which intervention is most important to include in the client's plan of care?
- A. Ensure the catheter is below the level of the bladder at all times.
- B. Change the catheter bag every 48 hours.
- C. Cleanse the perineal area daily.
- D. Perform catheter care daily.
Correct Answer: A
Rationale: The correct answer is to ensure the catheter is always below the level of the bladder. Placing the catheter tubing above the level of the bladder can lead to backflow of urine, causing urinary tract infections. Changing the catheter bag every 48 hours is important but not as crucial as maintaining proper catheter positioning. Cleaning the perineal area daily and performing catheter care are essential tasks but do not directly address the prevention of complications associated with catheter placement.
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The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding is most concerning?
- A. Increased fatigue
- B. Headache
- C. Elevated blood pressure
- D. Low urine output
Correct Answer: C
Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, an elevated blood pressure is the most concerning assessment finding. This finding can indicate worsening hypertension, which requires prompt intervention to prevent complications such as cardiovascular events or further kidney damage. Increased fatigue (Choice A) is a common symptom in CKD and can be expected with the condition itself or the treatment. Headache (Choice B) can also occur but is less specific to CKD or its treatment. Low urine output (Choice D) is a concern in CKD but may not be directly related to erythropoietin therapy.
A client with pneumonia has arterial blood gases levels at: pH 7.33; PaCO2 49 mm/Hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?
- A. Institute coughing and deep breathing protocols.
- B. Administer oxygen via nasal cannula.
- C. Prepare for intubation and mechanical ventilation.
- D. Increase IV fluids to improve hydration.
Correct Answer: A
Rationale: The ABG results indicate respiratory acidosis due to an elevated PaCO2 (49 mm/Hg), indicating hypoventilation. The appropriate intervention for respiratory acidosis is to improve ventilation. Coughing and deep breathing protocols can help the client to effectively ventilate and improve gas exchange. Administering oxygen via nasal cannula (Choice B) may be necessary in respiratory distress situations, but addressing the underlying cause of hypoventilation is crucial. Intubation and mechanical ventilation (Choice C) are not the first-line interventions for uncomplicated respiratory acidosis. Increasing IV fluids (Choice D) does not directly address the respiratory acidosis present in this scenario.
A client with cirrhosis is admitted with jaundice and ascites. Which laboratory value requires immediate intervention?
- A. Serum albumin of 3.0 g/dL
- B. Serum bilirubin of 3.0 mg/dL
- C. Serum ammonia level of 80 mcg/dL
- D. Serum sodium level of 135 mEq/L
Correct Answer: C
Rationale: A serum ammonia level of 80 mcg/dL is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. High serum ammonia levels can lead to altered mental status, confusion, and even coma. Serum albumin (choice A) is often decreased in cirrhosis but does not require immediate intervention. Serum bilirubin (choice B) elevation is expected in cirrhosis and may not require immediate intervention unless very high. Serum sodium (choice D) within the given range is generally acceptable and does not require immediate intervention.
The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding is most concerning?
- A. Increased fatigue
- B. Elevated blood pressure
- C. Low urine output
- D. Elevated hemoglobin
Correct Answer: B
Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, an elevated blood pressure is the most concerning assessment finding. Elevated blood pressure can indicate worsening hypertension, which requires immediate intervention. Increased fatigue may be expected due to anemia associated with CKD and erythropoietin therapy. Low urine output may indicate impaired kidney function but is not as immediately concerning as elevated blood pressure. Elevated hemoglobin levels are the desired outcome of erythropoietin therapy, indicating an appropriate response to treatment.
The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?
- A. Record urine output every hour
- B. Monitor blood pressure frequently
- C. Evaluate neurological status
- D. Maintain seizure precautions
Correct Answer: B
Rationale: Monitoring blood pressure frequently is the highest priority intervention for a client diagnosed with pheochromocytoma. This rare tumor can lead to life-threatening hypertension due to catecholamine secretion. Evaluating neurological status and maintaining seizure precautions are important but are not the highest priority in this case. Recording urine output, though essential for overall assessment, is not the priority compared to monitoring blood pressure in a client with pheochromocytoma.