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.
You may also like to solve these questions
A middle-aged woman talks to the nurse in the healthcare provider's office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?
- A. I am one of every 4 women that get fibroids, and among women my age - between the 30s or 40s, fibroids occur more frequently.
- B. My fibroids are noncancerous tumors that grow slowly.
- C. The associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination, urine retention, and constipation.
- D. Fibroids that cause no problems still need to be taken out.
Correct Answer: D
Rationale: The correct answer is D because fibroids that are asymptomatic usually do not require treatment or removal. The statement 'Fibroids that cause no problems still need to be taken out' indicates a need for further education. Choice A correctly states the frequency of fibroids in women and their age group. Choice B accurately describes fibroids as noncancerous slow-growing tumors. Choice C lists common symptoms associated with uterine fibroids.
A nurse is reinforcing teaching with a client who has COPD. Which of the following instructions by the nurse is appropriate?
- A. Drink carbonated beverages.
- B. Decrease fiber intake.
- C. Use bronchodilators after meals.
- D. Increase protein intake.
Correct Answer: D
Rationale: The correct answer is to instruct the client to increase protein intake. This is appropriate because increasing protein intake can help maintain muscle mass and strength in clients with COPD. Option A, 'Drink carbonated beverages,' is incorrect as carbonated beverages can exacerbate COPD symptoms. Option B, 'Decrease fiber intake,' is also incorrect as fiber is important for digestion and should not be decreased unless specifically advised by a healthcare provider. Option C, 'Use bronchodilators after meals,' is incorrect because bronchodilators are typically used before meals to help open the airways for better breathing, not after meals.
A nurse is reinforcing dietary teaching with a client who has iron deficiency anemia. The nurse should explain that which of the following food sources contains iron that is most easily absorbed by the body?
- A. Spinach
- B. Dried apricots
- C. Chicken
- D. Lentils
Correct Answer: C
Rationale: The correct answer is C, 'Chicken.' Heme iron from animal sources, such as chicken, is more easily absorbed by the body compared to non-heme iron from plant sources like spinach, dried apricots, and lentils. While plant-based iron sources are beneficial, they are not as readily absorbed by the body as heme iron from animal products.
The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?
- A. Stop the infusion
- B. Slow the rate of infusion
- C. Take vital signs and observe for further deterioration
- D. Administer Benadryl and continue the infusion
Correct Answer: A
Rationale: In the scenario of a client developing urticaria during a blood transfusion, the immediate priority for the nurse is to stop the infusion. This action is crucial to prevent further administration of the allergen causing the reaction. Slowing the rate of infusion (Choice B) may not be sufficient to address the allergic response effectively. While monitoring vital signs (Choice C) is important, stopping the infusion takes precedence to prevent worsening of the reaction. Administering Benadryl (Choice D) should be considered after stopping the infusion, following the healthcare provider's orders, and assessing the client's condition.
In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?
- A. Neurological status
- B. Cardiac status
- C. Respiratory status
- D. Gastrointestinal status
Correct Answer: B
Rationale: Corrected Rationale: Assessing cardiac status is crucial in hyperkalemia as high potassium levels can result in life-threatening arrhythmias. Monitoring the heart rhythm and ECG findings is essential to prevent cardiac complications. Neurological status, respiratory status, and gastrointestinal status are important assessments too, but in the context of hyperkalemia, cardiac status takes precedence due to the immediate risk of cardiac arrhythmias.