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An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
- A. Clear, dark amber-colored urine.
- B. Improved level of consciousness.
- C. Prothrombin time within normal limits.
- D. Decreased abdominal girth.
Correct Answer: D
Rationale: Decreased abdominal girth indicates reduced ascites, a direct result of low sodium diet and albumin infusions, which reduce fluid retention and increase oncotic pressure.
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A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
- A. Confirmation of the autoimmune disease process.
- B. Evidence of spread of the disease to the kidneys.
- C. Indication of the onset of joint degeneration.
- D. Representative of a decline in the client's condition.
Correct Answer: A
Rationale: Elevated rheumatoid factor is a marker of the autoimmune process in rheumatoid arthritis, confirming the diagnosis and indicating disease severity, not specific organ involvement or decline.
To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)
- A. Teach the client breathing exercises.
- B. Establish a regular bladder routine.
- C. Perform chest physiotherapy.
- D. Encourage use of incentive spirometer.
- E. Initiate passive range of motion exercises.
Correct Answer: A,C,D,E
Rationale: Breathing exercises, chest physiotherapy, incentive spirometer use, and passive range of motion exercises directly address respiratory function and mobility, reducing the risk of pulmonary complications in ALS by improving lung expansion, mobilizing secretions, and maintaining joint mobility.
While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?
- A. Calculate gestation from last menstrual cycle.
- B. Continue with surgery as scheduled.
- C. Perform a bedside pregnancy test.
- D. Notify the surgical team to cancel the surgery.
Correct Answer: C
Rationale: Performing a bedside pregnancy test immediately confirms or rules out pregnancy, ensuring safe surgical planning, as abdominal surgery poses risks to a fetus.
A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing food intake, the nurse should include which type of fluid limitation?
- A. Overall fluid intake.
- B. Tea and hot chocolate.
- C. Low-sodium soups.
- D. Citrus fruit juices.
Correct Answer: B
Rationale: Limiting tea and hot chocolate reduces oxalate intake, which can contribute to calcium oxalate stone formation, a common type of urinary tract calculi.
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use incentive spirometer.
- B. Monitor urinary stream for decrease in output.
- C. Report when hematuria becomes pink tinged.
- D. Restrict physical activities.
Correct Answer: B
Rationale: Monitoring urinary stream for decreased output is critical post-TUNA to detect complications like urinary retention or infection, ensuring kidney function and procedure effectiveness.