Nokea
A nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis due to the risk of which complication?
- A. Hyperglycemia
- B. Disequilibrium syndrome
- C. Peritonitis
- D. Hyperphosphatemia
- E. The client experiences pain upon palpation of the epigastric region.
Correct Answer: A
Rationale: Maintaining dwell time prevents excessive glucose absorption from dialysate which could cause hyperglycemia.
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A nurse is assessing a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
- A. Tachypnea
- B. Hypotension
- C. Decreased level of consciousness
- D. Bilateral weakness of extremities
Correct Answer: C
Rationale: Decreased LOC is the earliest and most sensitive sign of increased ICP.
A nurse is obtaining a health history for a client with chronic pancreatitis. Which of the following indicates the primary cause of the client's condition?
- A. Weight gain
- B. Use of alcohol
- C. Abdominal pain relieved with food or antacids
- D. Exposure to occupational chemicals
Correct Answer: B
Rationale: The use of alcohol is the most common cause of chronic pancreatitis, accounting for about 70% of cases.
A nurse is caring for a client who is receiving continuous enteral nutrition and develops refeeding syndrome. The nurse should expect which of the following laboratory findings?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypophosphatemia
Correct Answer: D
Rationale: Hypophosphatemia is the hallmark of refeeding syndrome due to intracellular shifts of phosphorus during refeeding.
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?
- A. Atropine
- B. Furosemide
- C. Heparin
- D. Dexamethasone
Correct Answer: C
Rationale: Heparin is an anticoagulant used in the initial treatment of pulmonary embolism to prevent further clot formation.
A nurse is teaching a client about self-administering peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching?
- A. The microwave in my kitchen can warm the solution before I use it.
- B. The catheter can become infected even with sterile precautions.
- C. The volume of the output solution should be greater than the input solution.
- D. The fluid from my abdomen will be clear or slightly yellow.
Correct Answer: A
Rationale: Microwaving can unevenly heat solution and is not recommended; solutions should be warmed using approved methods.