Nokea
Assessment of the client with an arteriovenous fistula for hemodialysis should include:
- A. inspection for visible pulsation.
- B. palpation of thrill.
- C. percussion for dullness.
- D. auscultation of blood pressure.
Correct Answer: B
Rationale: Thrill should be present. The client should be taught to check this daily at home. Pulsation is not typically visible. Percussion gives no information about the patency of a fistula. Blood pressure is not auscultated in a limb with an AVF. Auscultation of the AVF, for a bruit, is part of an assessment for patency.
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Which of the following observations is most important when assessing a client's breathing?
- A. presence of breathing and pulse rate
- B. breathing pattern and adequacy of breathing
- C. presence of breathing and adequacy of breathing
- D. patient position and adequacy of breathing
Correct Answer: C
Rationale: Ensuring the presence and adequacy of breathing is critical, as adequate oxygenation is essential for life. Pulse rate and position are secondary considerations.
When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
- A. When started, therapy must not be interrupted to prevent viral resistance
- B. When started, therapy must not be interrupted to prevent opportunistic infection
- C. Therapy should be interrupted for one day each month to prevent toxicity
- D. Therapy should be interrupted for one week every three months to prevent toxicity
Correct Answer: A
Rationale: HIV mutates very rapidly, and any interruption of therapy can allow viral resistance to emerge - even taking a dose late. Choice B is incorrect because, when the virus is kept in check with anti-retrovirals, the client's own immune system is able to keep opportunistic infections at bay. Choices C and D are incorrect because therapy should not be interrupted for any reason. If the client develops toxicity, another anti-retroviral drug might be prescribed.
A client newly diagnosed with Diabetes Mellitus needs education. Which of the following statements should the nurse include in this education?
- A. You can eat anything you want, but no foods with sugar.'
- B. You need to lose weight, so your diet must be a restricted one.'
- C. You need a diet and exercise program.'
- D. You must eliminate all salt, fat, and sugar from your diet.'
Correct Answer: C
Rationale: A balanced diet and exercise program are essential for managing diabetes, promoting glycemic control and overall health without extreme restrictions.
A nurse is working in a pediatric clinic and a 25 year-old mother comes in with a 4 week-old baby. The mother is stressed out about loss of sleep and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?
- A. Distraction of the infant with a red object
- B. Prone positioning techniques
- C. Tapping reflex techniques
- D. Neural warmth techniques
Correct Answer: D
Rationale: Neural warmth will help to lower the baby's agitation level, soothing the colic symptoms.
Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. primary health care prevention.
Correct Answer: B
Rationale: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment.