Nokea
A nurse is planning care for a client who is receiving hemodialysis. Which action should the nurse include in the care plan?
- A. Withhold all medications until after dialysis.
- B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
- C. Check the vascular access site for bleeding after dialysis.
- D. Give an antibiotic 30 minutes before dialysis.
Correct Answer: C
Rationale: The correct action the nurse should include in the care plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial as it helps in detecting and addressing any bleeding complications that may arise from the dialysis procedure. Choice A is incorrect because medications should not be withheld unless specified by the healthcare provider. Choice B is incorrect as dextrose 5% in water is not typically used for orthostatic hypotension. Choice D is incorrect as giving an antibiotic before dialysis is not a routine practice unless specifically prescribed for a particular reason.
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A client requests the creation of a living will. Which of the following actions should the nurse take?
- A. Schedule a meeting between the hospital ethics committee and the client
- B. Evaluate the client's understanding of life-sustaining measures
- C. Determine the client's preferences about post-mortem care
- D. Request a conference with the client's family
Correct Answer: B
Rationale: The correct action for the nurse to take when a client requests the creation of a living will is to evaluate the client's understanding of life-sustaining measures. This step is crucial to ensure that the client is well-informed about their options before making decisions regarding their future care. Scheduling a meeting with the hospital ethics committee (choice A) may not be necessary at this stage and could overwhelm the client. Determining the client's preferences about post-mortem care (choice C) is not directly related to creating a living will. Requesting a conference with the client's family (choice D) may be important later but is not the initial step in this situation.
A client with COPD is receiving discharge teaching. Which statement indicates an understanding of the teaching?
- A. I will avoid breathing deeply while using my incentive spirometer.
- B. I will limit my fluid intake to 1 liter per day.
- C. I will exercise in an area that is humid.
- D. I will use pursed-lip breathing techniques.
Correct Answer: D
Rationale: The correct answer is D. Using pursed-lip breathing techniques is beneficial for clients with COPD as it helps control shortness of breath by keeping airways open longer. Option A is incorrect as deep breathing while using an incentive spirometer is essential to prevent complications such as atelectasis. Option B is incorrect because limiting fluid intake to 1 liter per day is not a standard recommendation for clients with COPD. Option C is incorrect as exercising in a humid area can exacerbate breathing difficulties for clients with COPD.
A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian for which of the following clients?
- A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
- B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
- C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
- D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'
Correct Answer: B
Rationale: The correct answer is B. A client with gout who plans to continue consuming anchovies should be referred to a dietitian for proper dietary education. Anchovies are high in purines, which can exacerbate gout symptoms. Choices A, C, and D do not require immediate dietitian referral as the statements made by these clients are appropriate actions regarding their prescribed medications (warfarin and spinach intake, spironolactone and potassium intake, and calcium carbonate and water intake, respectively).
A client sustained a major burn over 20% of the body. What intervention should the nurse implement to meet the client's nutritional needs?
- A. Keep track of calorie intake for food and beverages.
- B. Provide a low-protein, high-carbohydrate diet.
- C. Schedule meals at 6-hour intervals.
- D. Provide a high-protein, high-calorie diet.
Correct Answer: D
Rationale: The correct answer is to provide a high-protein, high-calorie diet for a client with major burns. This type of diet is essential to support healing and recovery. High-protein intake is crucial as it helps in tissue repair and wound healing, while high-calorie intake is necessary to meet the increased metabolic demands of the body during the healing process. Keeping track of calorie intake (Choice A) is important but doesn't address the specific needs of a burn patient. Providing a low-protein, high-carbohydrate diet (Choice B) is not suitable for burn patients as they require adequate protein for wound healing. Scheduling meals at 6-hour intervals (Choice C) may be helpful for maintaining a consistent eating schedule, but it is not as crucial as providing the correct high-protein, high-calorie diet.
A client is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Measure the client's blood glucose level every 6 hours
- B. Change the TPN tubing every 24 hours
- C. Weigh the client weekly
- D. Administer the TPN through a peripheral IV line
Correct Answer: B
Rationale: The correct action for the nurse to take when caring for a client receiving total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. This practice helps reduce the risk of infection in clients receiving parenteral nutrition. Measuring the client's blood glucose level every 6 hours is important for clients on insulin therapy or with diabetes, but it is not directly related to TPN administration. Weighing the client weekly is essential for monitoring fluid status and nutritional progress, but it is not specific to TPN care. Administering TPN through a peripheral IV line is incorrect because TPN solutions are hypertonic and can cause phlebitis or thrombosis if administered through a peripheral line; a central venous access is typically used for TPN administration.