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Nurse Karen is caring for a client with chronic renal failure. Which is a correct intervention for hyperkalemia?
- A. assess patient for fever and chest pain
- B. assess patient for muscle weakness, diarrhea and ECG changes
- C. encourage compliance with fluid restriction
- D. prepare patient for cardiac ultrasound
Correct Answer: B
Rationale: The correct answer is B because hyperkalemia presents with symptoms such as muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common sign due to potassium's effect on neuromuscular function. Diarrhea can lead to potassium loss. ECG changes, such as peaked T waves and widened QRS complexes, indicate cardiac involvement. Assessing for these symptoms helps monitor the severity of hyperkalemia and guide treatment. Other choices are incorrect because assessing for fever and chest pain (choice A) are not specific to hyperkalemia. Encouraging fluid restriction (choice C) may not directly address hyperkalemia. Preparing for a cardiac ultrasound (choice D) is not an immediate intervention for hyperkalemia.
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A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
- A. Administer pain medication every 4 hours as needed.
- B. Turn the patient every 2 hours, even hours. NursingStoreRN
- C. Monitor vital signs, especially rhythm.
- D. Keep the bed side rails up at all times.
Correct Answer: B
Rationale: The correct answer is B because turning the patient every 2 hours helps prevent pressure ulcers caused by shearing forces. This intervention redistributes pressure, improving blood flow to the skin, thus reducing the risk of skin breakdown. Administering pain medication (A) does not directly address the skin integrity issue. Monitoring vital signs (C) is important but does not address skin integrity. Keeping bed rails up (D) may actually increase the risk of shearing forces.
What should a male client over age 50 do to help ensure early identification of prostate cancer?
- A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
- B. Have a transrectal ultrasound every 5 years
- C. Perform monthly testicular self-examinations, especially after age 50
- D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
Correct Answer: A
Rationale: The correct answer is A: Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. This is because regular screening with both tests can help detect prostate cancer early. The digital rectal exam allows the doctor to feel for any abnormalities in the prostate gland, while the PSA test measures the levels of a specific protein produced by the prostate gland. If there are any concerning findings, further diagnostic tests can be done to confirm prostate cancer.
Choice B is incorrect because transrectal ultrasound is not a recommended screening test for prostate cancer. Choice C is incorrect as testicular self-examinations are for detecting testicular cancer, not prostate cancer. Choice D is incorrect as CBC, BUN, and creatinine levels are not specific tests for prostate cancer screening.
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
- A. “I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear.”
- B. “I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal.”
- C. “I will receive parenteral vitamin B12 therapy monthly for 6 months to a year.”
- D. “I will receive parenteral vitamin B12 therapy for the rest of my life.”
Correct Answer: D
Rationale: The correct answer is D: “I will receive parenteral vitamin B12 therapy for the rest of my life.” This statement is correct because pernicious anemia is a lifelong condition requiring ongoing vitamin B12 supplementation. Patients with pernicious anemia lack intrinsic factor, which is needed to absorb vitamin B12 from food. Therefore, they need lifelong B12 therapy to prevent complications such as anemia and neurological damage.
Choices A, B, and C are incorrect because they suggest a limited duration of therapy. Pernicious anemia is a chronic condition that necessitates continuous treatment. Choice A implies therapy until signs and symptoms disappear, which may not address the underlying cause of the deficiency. Choice B mentions therapy until vitamin B12 levels normalize, which may not prevent recurrence. Choice C suggests monthly therapy for a fixed period, which may not be sufficient for lifelong management.
Which of the ff is a sign of urinary retention in older adults with a neurologic deficit?
- A. Amnesia
- B. Hypertension
- C. Hypotension
- D. A behaviour change
Correct Answer: D
Rationale: The correct answer is D, a behavior change. Urinary retention in older adults with a neurologic deficit can manifest as a behavior change, such as increased agitation, confusion, or restlessness due to discomfort from the inability to empty the bladder. Amnesia (A) is memory loss and not directly related to urinary retention. Hypertension (B) and hypotension (C) are related to blood pressure regulation and are not specific signs of urinary retention. In contrast, a behavior change (D) is a common and characteristic sign indicating urinary retention in this population.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. “Client will lose 2lb per week on a calorie-restricted diet.”
- B. “Client will exhibit no signs or symptoms of aspiration.”
- C. “Client will exhibit bowel and bladder continence.”
- D. “Client will exhibit alertness and orientation to person, place, and time.” DISTURBANCES IN IMMUNOLOGIC FUNCTIONING
Correct Answer: E
Rationale: I'm sorry, but it seems like the correct answer (E) is missing from the question. Could you please provide the correct answer so that I can provide you with a detailed explanation of why it is correct and summarize why the other choices are incorrect?