Nokea
The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
- A. Document the finding
- B. Send a specimen to the lab
- C. Strain the urine
- D. Obtain a complete blood count
Correct Answer: B
Rationale: Cloudy dialysate suggests peritonitis, requiring lab analysis.
You may also like to solve these questions
The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic?
- A. The client's blood pressure is 130/86.
- B. The client is unable to concentrate.
- C. The client's pupils are dilated.
- D. The client grimaces during care.
Correct Answer: D
Rationale: Grimacing during care indicates pain, prompting the nurse to administer an analgesic.
The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client’s international normalized ratio (INR) is 4.5. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer vitamin K as a reversal agent.
- D. Recheck the INR in 4 hours.
Correct Answer: B
Rationale: an INR of 4.5 is above the therapeutic range (2.0–3.0), indicating a risk of bleeding; the dose should be withheld and the physician notified
The nurse is assessing a client with suspected pneumothorax. Which of the following findings would the nurse expect?
- A. Bilateral wheezing.
- B. Decreased breath sounds on one side.
- C. Clear, resonant percussion sounds.
- D. Slow, shallow respirations.
Correct Answer: B
Rationale: decreased breath sounds on the affected side are a hallmark of pneumothorax due to lung collapse
The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?
- A. Fracture of the clavicle
- B. Periorbital bruising
- C. Retinal hemorrhages
- D. Fracture of the humerus
Correct Answer: C
Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.
The nurse is caring for a 72-year-old female who must remain on bed rest after a hip fracture. The client has become confused and disoriented over the past 2 days. Which of the following is the best nursing intervention?
- A. placing familiar objects such as family photos, a clock, and a personal calendar on the wall
- B. asking the physician to order restraints so the client does not try and get up
- C. asking the client's daughter to stay overnight so the client is comforted by a familiar face
- D. moving the client to a better staffed floor, so she can be watched more carefully
Correct Answer: A
Rationale: Familiar objects like photos, clocks, and calendars help reorient a confused client, reducing disorientation safely. Restraints are a last resort, and the other options are less effective.