Nokea
For a client with chronic kidney disease having a hemoglobin level of 8.0 g/dL, which intervention should the nurse perform first?
- A. Administer erythropoietin as ordered
- B. Monitor the client's blood pressure
- C. Monitor the client's oxygen saturation level
- D. Assess the client for signs of fatigue
Correct Answer: A
Rationale: Administering erythropoietin is the priority intervention for a client with chronic kidney disease and a low hemoglobin level. Erythropoietin stimulates red blood cell production, helping to manage anemia in these clients. Monitoring blood pressure, oxygen saturation level, and assessing for signs of fatigue are important aspects of care but addressing the anemia by administering erythropoietin takes precedence to improve oxygen-carrying capacity and overall well-being.
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The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg is the most concerning finding as it indicates poor blood flow, potentially suggesting a serious circulatory problem that requires immediate attention. Diminished bowel sounds, loss of appetite, and tachypnea may be relevant but are not as indicative of a critical circulatory issue as a cold, pale lower leg.
A client is being treated for congestive heart failure with furosemide (Lasix). Which of these findings would be most concerning to the nurse?
- A. Increased urine output
- B. Decreased appetite
- C. Weight loss of 2 kg in 24 hours
- D. Blood pressure of 140/90 mm Hg
Correct Answer: C
Rationale: The correct answer is C. A rapid weight loss of 2 kg in 24 hours suggests significant fluid loss, which is concerning in clients on diuretics like furosemide. Increased urine output (choice A) is an expected effect of diuretic therapy. Decreased appetite (choice B) is a common side effect but not as concerning as rapid weight loss. Blood pressure of 140/90 mm Hg (choice D) is slightly elevated but not the most concerning finding in a client being treated for congestive heart failure with furosemide.
A client is being treated for tuberculosis (TB). Which of these statements indicates the client understands the transmission of TB?
- A. I need to wear a mask when I go out in public to prevent spreading the infection.
- B. I need to take my medication as prescribed to prevent spreading the infection to others.
- C. I need to cover my mouth when I cough to prevent spreading the infection.
- D. I need to isolate myself from others until my treatment is complete to prevent spreading the infection.
Correct Answer: A
Rationale: The correct answer is A because wearing a mask in public can help prevent the spread of TB to others. Choice B is incorrect as taking medication as prescribed helps in treating the infection within the individual but does not directly prevent spreading it to others. Choice C is important for respiratory hygiene but may not be sufficient to prevent transmission. Choice D, isolation until treatment is complete, is crucial for preventing the spread but is not specifically about understanding transmission.
The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?
- A. Respiratory rate of 16 breaths per minute
- B. Blood pressure of 120/80 mm Hg
- C. Temperature of 99.5 degrees Fahrenheit
- D. Heart rate of 80 beats per minute
Correct Answer: C
Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.
Which of these findings would the nurse most closely associate with anemia in a 10-month-old infant?
- A. Hemoglobin level of 12 g/dL
- B. Pale mucosa of the eyelids and lips
- C. Hypoactivity
- D. A heart rate between 140 to 160
Correct Answer: B
Rationale: The correct answer is B. Pale mucosa of the eyelids and lips is a classic sign of anemia in infants, indicating a lack of sufficient red blood cells. This finding is due to decreased hemoglobin levels, which causes reduced oxygen delivery to tissues. Choices A, C, and D are less specific to anemia in infants. While a hemoglobin level of 12 g/dL may be within the normal range for a 10-month-old infant, the presence of pale mucosa is a more indicative sign of anemia.