Nokea
In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?
- A. High urinary pH
- B. Abdominal ascites
- C. Orthopnea
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Orthopnea. If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position. This means the head of the bed should be elevated as much as possible to facilitate catheter insertion without compromising the client's breathing. High urinary pH (choice A) is not directly relevant to the insertion position of a urinary catheter. Abdominal ascites (choice B) may impact the procedure due to abdominal distension but is not as crucial as orthopnea. Fever (choice D) does not specifically affect the client's position for urinary catheter insertion.
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The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding requires immediate intervention?
- A. Increased fatigue
- B. Elevated blood pressure
- C. Headache
- D. Elevated hemoglobin
Correct Answer: A
Rationale: The correct answer is A, 'Increased fatigue.' In a client with CKD receiving erythropoietin therapy, increased fatigue can be a sign of polycythemia, a condition characterized by an elevated red blood cell count. This can lead to increased blood viscosity and raise the risk of thromboembolic events, necessitating immediate intervention. Elevated blood pressure (choice B) is a common concern in CKD but does not require immediate intervention in this context. Headache (choice C) may be related to elevated blood pressure but is not the most critical finding requiring immediate attention. Elevated hemoglobin (choice D) is an expected outcome of erythropoietin therapy and does not require immediate intervention unless excessively high.
A client with a history of chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium level
- B. White blood cell count
- C. Hemoglobin level
- D. Serum calcium level
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level. In a client receiving erythropoietin therapy for chronic kidney disease, monitoring serum potassium levels is crucial due to the risk of hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increased demand for potassium. Monitoring potassium levels helps prevent complications associated with hyperkalemia. Choices B, C, and D are incorrect because erythropoietin therapy specifically impacts potassium levels, not white blood cell count, hemoglobin level, or serum calcium level.
A client with liver cirrhosis and severe ascites has a serum sodium level of 115 mEq/L and is receiving 3% saline IV. Which assessment finding indicates that the nurse should notify the healthcare provider?
- A. The client's serum sodium level is now 130 mEq/L
- B. The client reports a headache and has a BP of 140/90
- C. The client reports shortness of breath and has an O2 saturation of 92%
- D. The client has crackles in both lung bases and an increased respiratory rate.
Correct Answer: D
Rationale: The presence of crackles in both lung bases and an increased respiratory rate indicates fluid overload, which can be exacerbated by hypertonic saline. This condition can worsen the client's respiratory status and lead to further complications. The other options do not directly relate to the fluid overload caused by the hypertonic saline. A serum sodium level of 130 mEq/L is within a normal range for treatment. A headache and a blood pressure of 140/90 are not specific indicators of worsening condition related to hypertonic saline. Shortness of breath and an O2 saturation of 92% could be related to other factors in a client with liver cirrhosis and ascites.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Palpitations and shortness of breath
- B. Bradycardia and constipation
- C. Lethargy and lack of appetite
- D. Muscle cramping and dry, flushed skin
Correct Answer: A
Rationale: The correct answer is A. An overdose of thyroid preparation generally manifests symptoms of an agitated state such as tremors, palpitations, shortness of breath, tachycardia, increased appetite, agitation, sweating, and diarrhea. Palpitations and shortness of breath are signs of excessive thyroid medication. Choices B, C, and D are incorrect symptoms for a dosage that is too high. Bradycardia and constipation, lethargy and lack of appetite, muscle cramping and dry, flushed skin are more indicative of hypothyroidism or an insufficient dosage of levothyroxine.
A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a 'Do Not Resuscitate' prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take?
- A. Advise the UAP to resume positioning the client on schedule
- B. Notify the healthcare provider
- C. Document the UAP's actions
- D. Discuss the situation with the client's family
Correct Answer: A
Rationale: Continuing to turn the client is crucial to prevent complications such as pressure ulcers, even if the client is less responsive. Advising the UAP to resume positioning the client on schedule is the most appropriate action in this situation. This action ensures that the client's care needs are met and helps prevent potential complications. Notifying the healthcare provider or documenting the UAP's actions may delay the necessary care for the client. Discussing the situation with the client's family is important but addressing the immediate care need of turning the client takes priority.