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A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions should the nurse include in the teaching?
- A. Increase your intake of protein to 1 to 1.5 grams per kilogram per day.
- B. Reduce your fluid intake to 1L per day.
- C. Increase sodium intake to prevent hypotension.
- D. Monitor blood glucose levels daily.
Correct Answer: A
Rationale: The correct answer is A: Increase your intake of protein to 1 to 1.5 grams per kilogram per day. This is because patients undergoing hemodialysis often experience protein loss during the process. Adequate protein intake helps maintain muscle mass and supports overall health. Option B is incorrect as fluid restriction is typically recommended for patients on hemodialysis due to impaired fluid removal by the kidneys. Option C is incorrect as increasing sodium intake can lead to fluid retention and exacerbate hypertension, a common complication in chronic kidney disease. Option D is not directly related to hemodialysis and is more pertinent to diabetes management.
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A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the clients risk of developing breast cancer?
- A. Daily caffeine consumption
- B. A history of seasonal allergies
- C. Oral contraceptives were taken for the last 6 years
- D. Routine use of multivitamins
Correct Answer: C
Rationale: The correct answer is C: Oral contraceptives were taken for the last 6 years. Long-term use of oral contraceptives has been associated with a slightly increased risk of developing breast cancer. Estrogen and progesterone in oral contraceptives can stimulate the growth of breast tissue, potentially leading to cancer over time. Daily caffeine consumption (choice A) and a history of seasonal allergies (choice B) do not have a direct correlation with an increased risk of breast cancer. Routine use of multivitamins (choice D) is generally not linked to an increased risk of breast cancer.
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
- A. Peripheral neuropathy
- B. Hypertension
- C. Retinopathy
- D. Stroke
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes mellitus, microvascular complications involve damage to small blood vessels. Retinopathy specifically affects the blood vessels in the retina, leading to vision problems. Peripheral neuropathy (A) is a macrovascular complication affecting nerves. Hypertension (B) is a common comorbidity in diabetes but not a direct microvascular complication. Stroke (D) is a macrovascular complication involving larger blood vessels in the brain. Therefore, the presence of retinopathy is a clear indication of a microvascular complication in a client with type 2 diabetes mellitus.
A nurse is teaching a client about self-management of their halo fixator device. Which of the following information should the nurse include in the teaching?
- A. Place a small pillow under the head while lying supine.
- B. Remove the vest for comfort while sleeping.
- C. Apply lotion under the vest to reduce irritation.
- D. Adjust the screws if the device feels loose.
Correct Answer: A
Rationale: The correct answer is A: Place a small pillow under the head while lying supine. This is important to prevent hyperextension of the neck while lying down, ensuring proper alignment and comfort. Removing the vest (B) compromises stability. Applying lotion (C) can cause skin breakdown. Adjusting screws (D) without proper training can lead to complications.
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply)
- A. Ferrous sulfate
- B. Echinacea
- C. Aspirin
- D. Dextromethorphan
- E. Naproxen
Correct Answer: C, E
Rationale: The correct answer is C (Aspirin) and E (Naproxen). Aspirin and Naproxen are both NSAIDs that can increase the risk of bleeding when taken with warfarin, which is an anticoagulant. The combination can lead to excessive anticoagulation and potential bleeding complications. Ferrous sulfate (A) does not interact significantly with warfarin. Echinacea (B) is an herbal supplement that may have interactions with some medications, but not warfarin specifically. Dextromethorphan (D) is a cough suppressant and does not have a significant interaction with warfarin. In summary, Aspirin and Naproxen should be avoided with warfarin due to the increased risk of bleeding, while the other options do not have significant interactions with warfarin.
A nurse is caring for a client who is receiving vancomycin intermittent IV bolus therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the medication?
- A. The client reports ringing in the ears.
- B. The client is becoming flushed.
- C. The client reports increased thirst.
- D. The client has a decreased urine output.
Correct Answer: B
Rationale: The correct answer is B: The client is becoming flushed. Flushing is a common adverse effect of vancomycin, indicating a possible allergic reaction or infusion reaction. Flushing can be a sign of red man syndrome, a severe reaction to vancomycin. The nurse should monitor closely and report this finding to the healthcare provider.
Incorrect Answer Rationale:
A: The client reports ringing in the ears - this is a potential adverse effect of vancomycin, but not as critical as flushing.
C: The client reports increased thirst - this is not typically associated with vancomycin adverse effects.
D: The client has a decreased urine output - this may indicate nephrotoxicity, a known side effect of vancomycin, but flushing is more indicative of an immediate adverse reaction.