Nokea
A nurse is reinforcing discharge teaching with a client who has osteoarthritis. Which of the following statements by the client indicates an understanding of the teaching?
- A. Osteoarthritis is caused by inflammation that affects both joints and other body tissues.
- B. Osteoarthritis happens in several phases when deposits of crystals develop in joints and soft tissues.
- C. Osteoarthritis occurs due to the aging process and results in disintegration of cartilage in a joint.
- D. Osteoarthritis is due to loss of calcium in the bones, which can lead to increased risk for bone fractures.
Correct Answer: C
Rationale: Osteoarthritis is a degenerative joint disease due to aging and cartilage disintegration, as correctly understood.
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A nurse is assisting with the care of a client who has hypertension and chronic kidney disease. The client is scheduled for hemodialysis. Which of the following actions should the nurse plan to take while caring for this client? (Select all that apply.)
- A. Obtain the client's weight.
- B. Verify the glomerular filtration rate.
- C. Check the graft site for a palpable thrill.
- D. Document vital signs.
- E. Administer a sedative to the client.
Correct Answer: A,C,D
Rationale: Obtaining the client's weight, checking the graft site for a palpable thrill, and documenting vital signs are essential to monitor fluid balance, ensure vascular access functionality, and detect complications during hemodialysis.
A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?
- A. Notify the charge nurse.
- B. Check the client's vital signs.
- C. Fill out an occurrence report according to institutional policy.
- D. Document an objective description of what has happened in the client's chart.
Correct Answer: B
Rationale: Checking the client's vital signs is the priority to assess for adverse effects, such as hypotension, ensuring immediate safety.
A nurse is admitting a client who reports recurrent flank pain and nausea for 24 hr. Which of the following actions should the nurse take first?
- A. Monitor intake and output.
- B. Administer pain medication.
- C. Ambulate in hall.
- D. Strain the urine.
Correct Answer: B
Rationale: Administering pain medication is the priority to alleviate discomfort, allowing for further assessment and treatment.
A nurse is collecting data on a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should recognize which of the following findings is the priority?
- A. The client has small blood clots in his urinary catheter.
- B. The client reports a continuous urge to void.
- C. The client reports burning around the urinary catheter.
- D. The client has bright red urine in his urinary catheter.
Correct Answer: D
Rationale: Bright red urine indicates active bleeding, a serious complication requiring immediate attention to prevent hemorrhage.
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following findings should the nurse expect?
- A. Frothy sputum.
- B. Dependent edema.
- C. Jugular distention.
- D. Nocturnal polyuria.
Correct Answer: A
Rationale: Frothy sputum is a symptom of left-sided heart failure due to pulmonary congestion and edema.