Nokea
The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client?
- A. Notify the HCP if oral temperature is 102°F or greater.
- B. Apply ice to the access site if it starts bleeding at home.
- C. Keep fingernails short and try not to scratch the skin.
- D. Encourage the significant other to make decisions for the client.
Correct Answer: A
Rationale: A fever of 102°F or higher may indicate infection, a serious complication in hemodialysis patients, requiring prompt HCP notification. Ice may worsen bleeding, short nails are general advice, and encouraging dependency is not therapeutic.
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What is the primary reason for administering a laxative before the procedure?
- A. To the bowel aids in examining the lower GI tract.
- B. Emptying the bowel prevents accidental stool incontinence during the X-ray.
- C. Emptying the bowel reduces the potential for constipation or impaction.
- D. Emptying the bowel improves the ability to visualize the urinary structures.
Correct Answer: D
Rationale: Emptying the bowel before intravenous pyelography (IVP) enhances visualization of the urinary structures by reducing interference from fecal matter.
The nurse writes the client problem of 'fluid volume excess' (FVE). Which intervention should be included in the plan of care?
- A. Change the IV fluid from 0.9% NS to D5W.
- B. Restrict the sodium in the client’s diet.
- C. Monitor blood glucose levels.
- D. Prepare the client for hemodialysis.
Correct Answer: B
Rationale: Restricting sodium reduces fluid retention in FVE, as sodium promotes water reabsorption. D5W provides free water, worsening FVE; glucose monitoring is unrelated; and hemodialysis is reserved for severe cases.
The nurse is caring for a client with a TURP. Which expected outcome indicates the client’s condition is improving?
- A. The client is using the maximum amount allowed by the PCA pump.
- B. The client’s bladder spasms are relieved by medication.
- C. The client’s scrotum is swollen and tender with movement.
- D. The client has passed a large, hard, brown stool this morning.
Correct Answer: B
Rationale: Relief of bladder spasms indicates reduced irritation and healing post-TURP. Maximum PCA use, scrotal swelling, or hard stools do not reflect improvement and may indicate complications.
When the client complains about the bland taste of the food, the nurse appropriately recommends substituting salt with which condiment?
- A. Catsup
- B. Mustard
- C. Soy sauce
- D. Lemon juice
Correct Answer: D
Rationale: Lemon juice is a low-sodium flavor enhancer, suitable for a sodium-restricted diet, unlike catsup, mustard, or soy sauce.
The client diagnosed with cancer of the bladder states, 'I have young children. I am too young to die.' Which statement is the nurse’s best response?
- A. This cancer is treatable and you should not give up.'
- B. Cancer occurs at any age. It is just one of those things.'
- C. You are afraid of dying and what will happen to your children.'
- D. Have you talked to your children about your dying?'
Correct Answer: C
Rationale: Reflecting the client’s fear of dying and concern for their children validates emotions and encourages dialogue. Reassurance, generalizing cancer, or prompting child discussions may dismiss the client’s feelings.