Nokea
In the oliguric phase of acute renal failure, the nurse should assess the client for:
- A. Pulmonary edema.
- B. Metabolic alkalosis.
- C. Hypotension.
- D. Hypokalemia.
Correct Answer: A
Rationale: Pulmonary edema is a risk in the oliguric phase due to fluid overload from reduced urine output.
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A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, 'Why does she have this tube inserted in her hip?' Which of the following responses would be best?
- A. The tube helps us to detect a wound infection early on.'
- B. This way we won't have to irrigate the wound.'
- C. Fluid won't be allowed to accumulate at the site.'
- D. We have a way to administer antibiotics into the wound.'
Correct Answer: C
Rationale: The drainage tube prevents fluid accumulation, reducing infection risk and promoting healing.
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
- A. Stage I pressure ulcer.
- B. Stage II pressure ulcer.
- C. Stage III pressure ulcer.
- D. Stage IV pressure ulcer.
Correct Answer: B
Rationale: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation?
- A. An obstruction is present in the chest tube.
- B. The client is developing subcutaneous emphysema.
- C. The chest tube system is functioning properly.
- D. There is a leak in the chest tube system.
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates a patent chest tube system, reflecting pleural pressure changes. Obstruction, emphysema, or leaks would show different signs.
A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which of the following changes in her husband's behavior may confirm her fears?
- A. Increased decisiveness.
- B. Problem-focused coping style.
- C. Increase in social interactions.
- D. Disturbance in his sleep patterns.
Correct Answer: D
Rationale: Sleep disturbances are a common symptom of depression, suggesting the husband may be struggling emotionally with his wife's diagnosis.
A client with uric acid stones is prescribed a low-purine diet. Which food is allowed?
- A. Liver.
- B. Chicken.
- C. Apples.
- D. Sardines.
Correct Answer: C
Rationale: Apples are low in purines, suitable for a uric acid stone diet.