Nokea
A nurse is caring for a patient with a history of chronic kidney disease. The nurse should monitor for which of the following complications related to decreased renal function?
- A. Hyperkalemia.
- B. Hypoglycemia.
- C. Hypotension.
- D. Hypercalcemia.
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In chronic kidney disease, the kidneys are unable to effectively excrete potassium, leading to elevated levels in the blood. This can result in life-threatening cardiac arrhythmias. Monitoring for hyperkalemia is crucial in managing patients with kidney disease.
Other choices are incorrect because:
B: Hypoglycemia is not typically associated with chronic kidney disease.
C: Hypotension may occur in kidney disease but is not directly related to decreased renal function.
D: Hypercalcemia is not a common complication of decreased renal function; in fact, kidney disease can lead to low levels of calcium.
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What is the most important nursing intervention for a client with pneumonia?
- A. Administer antibiotics
- B. Administer fluids
- C. Monitor temperature
- D. Administer vaccines
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating pneumonia caused by bacteria. They help to kill the bacteria causing the infection and prevent its spread. Administering fluids (B) is important for hydration but not the most crucial intervention. Monitoring temperature (C) is important but does not treat the root cause. Administering vaccines (D) may prevent certain types of pneumonia but is not the immediate intervention for an existing infection. Administering antibiotics promptly is vital to effectively treat pneumonia and prevent complications.
Which of the following actions is the nurse's priority when caring for a client with a head injury?
- A. Monitor the client's airway
- B. Administer pain relief
- C. Perform a CT scan
- D. Monitor intracranial pressure
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's airway. This is the priority because airway management is crucial in ensuring adequate oxygenation and ventilation, which is essential for brain function in a client with a head injury. Maintaining a clear airway takes precedence over other actions such as administering pain relief, performing a CT scan, or monitoring intracranial pressure. While these actions are important, ensuring the client's airway is patent and adequate oxygenation is crucial for preventing further brain injury or complications.
Which of the following actions is the nurse's priority when caring for a client with a suspected stroke?
- A. Assess the client's neurologic status
- B. Start an intravenous line and administer thrombolytics
- C. Monitor the client's ECG
- D. Provide emotional support
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's ECG. This is the priority because it helps in detecting any cardiac abnormalities or arrhythmias which are common in stroke patients. Assessing neurologic status (A) is important but monitoring the ECG takes precedence. Starting an IV line and administering thrombolytics (B) should be done as per protocol but is not the immediate priority. Providing emotional support (D) is important, but ensuring the client's cardiac status is stable is crucial in the acute phase of stroke.
What does the Health Insurance Portability and Accountability Act (HIPAA) regulate?
- A. Who will provide client care
- B. Privacy of information
- C. How insurance information is obtained
- D. Where a chart can be stored
Correct Answer: B
Rationale: The correct answer is B because HIPAA regulates the privacy and security of protected health information. This includes how healthcare providers, insurers, and other entities handle and safeguard patient information to ensure confidentiality. Choice A is incorrect as HIPAA does not dictate who provides client care. Choice C is incorrect as HIPAA focuses on the protection of health information, not how insurance information is obtained. Choice D is incorrect as HIPAA does not specify where a chart can be stored, but rather how the information within it is protected.
What is the first action the nurse should take when a client develops a deep vein thrombosis (DVT)?
- A. Elevate the affected leg
- B. Apply compression stockings
- C. Provide leg elevation
- D. Administer compression therapy
Correct Answer: A
Rationale: The correct answer is A: Elevate the affected leg. This is the first action because elevating the leg helps reduce swelling and improve blood flow, reducing the risk of complications from the DVT. It also helps alleviate pain.
Choice B: Applying compression stockings can be helpful in preventing DVT, but it is not the first action to take once it has developed.
Choice C: Providing leg elevation is similar to choice A, but it lacks the specificity of elevating the affected leg to address the DVT directly.
Choice D: Administering compression therapy may be necessary, but it is not the initial action to take when a client develops a DVT.