Nokea
The client has had hypertension for 20 years. The nurse should assess the client for?
- A. Renal insufficiency and failure.
- B. Valvular heart disease.
- C. Endocarditis.
- D. Peptic ulcer disease.
Correct Answer: A
Rationale: Long-standing hypertension damages kidneys, leading to renal insufficiency or failure, a common complication requiring assessment.
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The client's serum potassium level is elevated in acute renal failure, and the nurse administers sodium polystyrene sulfonate (Kayexalate). This drug acts to:
- A. Increase potassium excretion from the colon.
- B. Release hydrogen ions for sodium ions.
- C. Increase calcium absorption in the colon.
- D. Exchange sodium for potassium ions in the colon.
Correct Answer: D
Rationale: Kayexalate exchanges sodium for potassium in the colon, reducing serum potassium levels in acute renal failure.
After stabilization of Addison's disease, the nurse teaches the client about stress management. The nurse should instruct the client to:
- A. Remove all sources of stress from daily life.
- B. Use relaxation techniques such as music.
- C. Take antianxiety drugs daily.
- D. Avoid discussing stressful experiences.
Correct Answer: B
Rationale: Relaxation techniques like music help manage stress, reducing glucocorticoid demands in Addison's disease.
A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome?
- A. The client drinks 2,000 mL of fluid per day.
- B. The client understands how to manage the incision.
- C. The client's bed linens are changed as needed.
- D. The client's skin remains cool throughout hospitalization.
Correct Answer: A
Rationale: Drinking 2,000 mL of fluid daily addresses fluid volume deficit due to diaphoresis.
Complications associated with a tracheostomy tube include:
- A. Decreased cardiac output.
- B. Damage to the laryngeal nerve.
- C. Pneumothorax.
- D. Acute respiratory distress syndrome (ARDS).
Correct Answer: C
Rationale: Pneumothorax is a potential complication of tracheostomy tube placement due to possible injury to the lung or pleural space during insertion or maintenance.
A client with a spinal fusion is using a transcutaneous electrical nerve stimulation (TENS) unit for pain relief. Which client statement indicates correct use?
- A. I'll place the electrodes directly over the incision.'
- B. I'll adjust the intensity to a comfortable level.'
- C. I'll use the unit for 12 hours continuously.'
- D. I'll apply the unit to my lower legs.'
Correct Answer: B
Rationale: Adjusting the TENS unit to a comfortable intensity ensures effective and safe pain relief.