Nokea
The client with diabetes mellitus is being taught how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.)
- A. I can continue to take an aspirin every 4 to 8 hours for my pain.
- B. My weight should be maintained at a body mass index of 30.
- C. Smoking should be stopped as soon as possible.
- D. A & B
Correct Answer: D
Rationale: The correct answer is D. Both statements A and B indicate a lack of understanding of CKD prevention. Taking aspirin every 4 to 8 hours can lead to kidney damage, and maintaining a body mass index (BMI) of 30 is considered overweight, which can increase the risk of developing CKD. Statement C, on the other hand, correctly addresses smoking cessation, which is crucial in preventing CKD. Therefore, choices A and B are incorrect as they do not align with CKD prevention strategies, making option D the correct choice.
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A patient is being treated for shock after a motor vehicle accident. The provider orders 6% dextran 75 to be given intravenously. The nurse should expect which outcome as the result of this infusion?
- A. Decreased urine output
- B. Improved blood oxygenation
- C. Increased interstitial fluid
- D. Stabilization of heart rate and blood pressure
Correct Answer: D
Rationale: 6% Dextran 75 is a high molecular-weight colloidal solution used to treat shock from burns or trauma. Colloids like 6% dextran 75 are plasma expanders that help increase blood volume, leading to improved heart rate and blood pressure stabilization. The infusion of plasma expanders does not typically decrease urine output. It primarily aims to stabilize circulation rather than affect blood oxygenation or increase interstitial fluid levels.
A client with a chest tube attached to a closed drainage system has undergone a chest x-ray, which revealed that the affected lung is fully reexpanded. The nurse anticipates that the next assessment of the chest tube system will reveal:
- A. No fluctuation in the water seal chamber
- B. Continuous bubbling in the water seal chamber
- C. Increased drainage in the collection chamber
- D. Continuous gentle suction in the suction control chamber
Correct Answer: A
Rationale: When the client's lung is fully reexpanded, the chest tube drainage system will no longer be actively draining, and there will be no fluctuation in the water seal chamber. Option B, continuous bubbling in the water seal chamber, indicates an air leak in the system, which is not expected when the lung is fully expanded. Option C, increased drainage in the collection chamber, would not be expected when the lung is reexpanded as there should be minimal to no drainage. Option D, continuous gentle suction in the suction control chamber, would not be appropriate when the lung is fully reexpanded and the chest tube is typically on a water seal system at this point to promote reexpansion and prevent air from entering the pleural space.
A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention?
- A. A 29-year-old client after a difficult vaginal delivery - Habit training
- B. A 58-year-old postmenopausal client who is not taking estrogen therapy - Electrical stimulation
- C. A 64-year-old female with Alzheimer's-type senile dementia - Bladder training
- D. A 77-year-old female who has difficulty ambulating - Exercise therapy
Correct Answer: B
Rationale: The correct pairing is a 58-year-old postmenopausal client who is not taking estrogen therapy with electrical stimulation. Electrical stimulation is used for clients with stress incontinence related to menopause and low estrogen levels. Exercise therapy improves pelvic wall strength and is not specifically for ambulation issues. Habit training is more effective for cognitively impaired clients, like those with Alzheimer's-type senile dementia. Bladder training requires the client to be alert, aware, and able to resist the urge to urinate, which may not be suitable for clients with cognitive impairments.
A client is being taught about self-catheterization in the home setting. Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Wash your hands before and after self-catheterization.
- B. Use lubricant on the tip of the catheter before insertion.
- C. A & B
- D. Self-catheterize at least twice a day or every 12 hours.
Correct Answer: C
Rationale: In teaching a client about self-catheterization, it is essential to emphasize proper hand hygiene before and after the procedure to prevent infections. Using lubricant on the catheter helps with insertion and reduces discomfort. Therefore, statements A and B are correct and should be included in the client's teaching. Option D is incorrect because self-catheterization frequency should be individualized based on the client's needs, and a specific time frame like every 12 hours may not be suitable for everyone. Choosing a smaller lumen catheter is preferred over a larger one. Self-catheterization should not be limited to a specific time frame but should be based on the individual's needs and voiding patterns. Therefore, option C is the correct choice as it includes the two essential statements for teaching self-catheterization in the home setting.
The nurse is preparing to give trimethoprim-sulfamethoxazole (TMP-SMX) to a patient and notes a petechial rash on the patient's extremities. The nurse will perform which action?
- A. Hold the dose and notify the provider.
- B. Request an order for a blood glucose level.
- C. Request an order for a BUN and creatinine level.
- D. Request an order for diphenhydramine (Benadryl).
Correct Answer: A
Rationale: When a patient on TMP-SMX presents with a petechial rash, it can be indicative of a severe adverse reaction such as thrombocytopenia or a hypersensitivity reaction. The appropriate action for the nurse to take in this situation is to hold the dose of TMP-SMX and notify the healthcare provider immediately. This is crucial to prevent further administration of a medication that may be causing a serious adverse effect. Requesting a blood glucose level (Choice B) is not relevant in this scenario as the patient's presentation is suggestive of a skin-related issue rather than a glucose-related problem. Similarly, requesting a BUN and creatinine level (Choice C) would not address the immediate concern of a petechial rash and its association with TMP-SMX. Requesting an order for diphenhydramine (Choice D) may help manage itching or mild allergic reactions but is not the priority when a petechial rash is observed, as it may indicate a more severe reaction requiring immediate intervention.