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The healthcare provider is assessing a client who has a new arteriovenous fistula in the left arm for hemodialysis. Which finding requires immediate intervention?
- A. A thrill is palpable on the fistula.
- B. The client's arm is warm and red.
- C. The fistula has a bruit on auscultation.
- D. There is no bruit on auscultation.
Correct Answer: B
Rationale: The correct answer is B. Warmth and redness in the client's arm suggest infection or thrombosis of the arteriovenous fistula, which requires immediate intervention to prevent complications. A thrill (A) is a normal finding in a functional arteriovenous fistula, indicating good blood flow. A bruit (C) is also a normal finding on auscultation of a functioning arteriovenous fistula, indicating proper blood flow. The absence of a bruit (D) may indicate a non-functioning fistula, which would need further evaluation but does not require immediate intervention as warmth and redness do.
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The nurse must delegate some aspects of a homebound client's care to a home health aide. Which intervention should the nurse delegate to the home health aide?
- A. evaluating a pressure sore
- B. applying a prosthetic device
- C. performing a sterile dressing change
- D. assessing the client's need for an elevated toilet seat
Correct Answer: B
Rationale: The correct answer is B: applying a prosthetic device. Home health aides are trained and authorized to assist with the application and management of prosthetic devices for clients. Evaluating a pressure sore (choice A) requires clinical assessment and judgment typically performed by a licensed healthcare provider such as a nurse. Performing a sterile dressing change (choice C) involves aseptic technique and wound care skills that are usually performed by licensed healthcare professionals. Assessing the client's need for an elevated toilet seat (choice D) involves a level of assessment and decision-making that is beyond the scope of practice for a home health aide.
The healthcare provider is assessing a client who has returned from hemodialysis. Which finding requires immediate intervention?
- A. Weight gain of 1 pound.
- B. Dizziness.
- C. Fatigue.
- D. Muscle cramps.
Correct Answer: D
Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.
The school nurse is developing an individualized healthcare plan for a student with type 1 diabetes. Which component is most important to include in the plan?
- A. a schedule for blood glucose monitoring
- B. a list of low-carbohydrate snacks
- C. a contact list of healthcare providers
- D. a log for recording insulin administration
Correct Answer: A
Rationale: The correct answer is A: a schedule for blood glucose monitoring. Regular blood glucose monitoring is essential in managing type 1 diabetes as it helps in monitoring blood sugar levels, adjusting treatment plans, and preventing complications such as hypoglycemia or hyperglycemia. Choice B, a list of low-carbohydrate snacks, while important for managing blood sugar levels, is not as critical as consistent blood glucose monitoring. Choice C, a contact list of healthcare providers, though important for emergency situations, is not the most crucial component in managing daily care. Choice D, a log for recording insulin administration, is valuable for tracking insulin doses but does not directly address the immediate need for monitoring blood glucose levels.
The healthcare provider is caring for a client with hyperparathyroidism. Which laboratory result requires immediate intervention?
- A. Serum calcium of 11 mg/dL.
- B. Serum phosphorus of 3 mg/dL.
- C. Serum magnesium of 1.8 mg/dL.
- D. Serum albumin of 4 g/dL.
Correct Answer: A
Rationale: A serum calcium level of 11 mg/dL indicates hypercalcemia, which can be a complication of hyperparathyroidism and requires immediate intervention. Hypercalcemia can lead to serious complications such as cardiac dysrhythmias, renal failure, and neurologic symptoms. Monitoring and managing serum calcium levels are crucial in clients with hyperparathyroidism. Serum phosphorus, magnesium, and albumin levels are important to assess in clients with hyperparathyroidism, but they do not require immediate intervention as hypercalcemia poses a more urgent risk.
The healthcare provider provides teaching to a group of evacuees in a mass casualty center after a natural flooding disaster. Which information should the healthcare provider include in the teaching plan? (select one that does not apply.)
- A. wash all fruits and vegetables thoroughly in running tap water
- B. identify all sexual contacts since the evacuation process
- C. take all doses of prophylactic prescriptions for diarrhea
- D. clean hands using soap, clean water, or waterless antibacterial solutions
Correct Answer: B
Rationale: In the aftermath of a flooding disaster, educating evacuees on proper hygiene practices like washing fruits and vegetables, taking prophylactic prescriptions, and practicing hand hygiene is crucial to prevent the spread of diseases. Option B, identifying sexual contacts, is not relevant to preventing post-disaster health risks and should not be included in the teaching plan.