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A nurse is performing a risk assessment for a client. Which of the following factors should the nurse identify as increasing the clients risk for falls?
- A. The client had cataract surgery 1 day ago.
- B. The client uses a hearing aid.
- C. The client has a history of hypertension.
- D. The client has a history of constipation.
Correct Answer: A
Rationale: Correct Answer: A. The client had cataract surgery 1 day ago.
Rationale: Cataract surgery can lead to temporary visual impairment, affecting depth perception and balance, increasing fall risk.
Summary:
B: Using a hearing aid does not directly increase fall risk.
C: History of hypertension does not directly increase fall risk for falls.
D: History of constipation does not directly increase fall risk for falls.
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A nurse is caring for a client who has acute kidney injury and a potassium level of 6.5 mEq/L. Which of the following ECG changes should the nurse expect?
- A. Flattened T waves
- B. Peaked T waves
- C. Prolonged PR interval
- D. ST segment depression
Correct Answer: B
Rationale: The correct answer is B: Peaked T waves. In hyperkalemia (high potassium level), the myocardium becomes more excitable, leading to changes in the ECG. Peaked T waves are a classic sign of hyperkalemia, indicating early stages of cardiac involvement. Flattened T waves (choice A) are associated with hypokalemia. Prolonged PR interval (choice C) and ST segment depression (choice D) are not typically seen in hyperkalemia.
A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of the following statements should the nurse include in the teaching?
- A. Avoid high-fat cuts of meat.
- B. Increase your intake of fried foods.
- C. Consume dairy products at every meal.
- D. Eat large meals to avoid frequent digestion.
Correct Answer: A
Rationale: The correct answer is A: Avoid high-fat cuts of meat. Cholelithiasis is the formation of gallstones, often related to high-fat diets. High-fat cuts of meat can trigger gallbladder contractions, leading to pain. The rationale is to reduce fat intake to prevent further gallstone formation. Choices B, C, and D are incorrect. B: Increasing fried foods can exacerbate symptoms due to their high-fat content. C: Consuming dairy products at every meal is not recommended as some dairy products can be high in saturated fats. D: Eating large meals can overload the digestive system, potentially leading to gallbladder discomfort.
A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the clients plan of care?
- A. Assess the PICC infusion system systematically.
- B. Flush the line only before infusing medication.
- C. Use a sterile dressing for the catheter site every 7 days.
- D. Allow the catheter to remain uncapped when not in use.
Correct Answer: A
Rationale: The correct answer is A: Assess the PICC infusion system systematically. This is essential to monitor for signs of infection, occlusion, or dislodgement of the catheter. Regular assessment can help identify any issues early and prevent complications.
Summary:
B: Flushing the line only before infusing medication is incorrect as regular flushing is necessary to maintain catheter patency.
C: Using a sterile dressing every 7 days is incorrect as the dressing should be changed according to facility protocol or if it becomes soiled or loose.
D: Allowing the catheter to remain uncapped when not in use is incorrect as it can increase the risk of contamination and infection.
A nurse is caring for a client who has dumping syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Iron-deficiency anemia
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Iron-deficiency anemia. Dumping syndrome following a gastric resection can lead to rapid emptying of the stomach contents into the small intestine, causing malabsorption of nutrients, especially iron. Iron-deficiency anemia can develop due to inadequate iron absorption. Monitoring for anemia is crucial in these clients.
Hyperkalemia (A), hypoglycemia (B), and hypertension (D) are not typical complications of dumping syndrome. Hyperkalemia is high potassium levels, hypoglycemia is low blood sugar, and hypertension is high blood pressure, which are not directly associated with dumping syndrome.
A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the following quadrants should the nurse anticipate the client to be experiencing abdominal pain?
- A. Right lower quadrant
- B. Left lower quadrant
- C. Upper left quadrant
- D. Mid-epigastric area
Correct Answer: B
Rationale: The correct answer is B: Left lower quadrant. Diverticular disease commonly causes pain in the left lower quadrant due to inflammation or infection of the diverticula, small pouches that can develop in the colon wall. This area corresponds to the location of the descending and sigmoid colon, where most diverticula occur. Pain in the right lower quadrant (choice A) is more indicative of appendicitis. Upper left quadrant pain (choice C) is more likely related to conditions involving the spleen or stomach. Mid-epigastric pain (choice D) is typically associated with issues related to the stomach or pancreas.