Nokea
The healthcare provider is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding is most concerning?
- A. Increased fatigue
- B. Elevated blood pressure
- C. Elevated hemoglobin
- D. Low urine output
Correct Answer: B
Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure is the most concerning finding. Elevated blood pressure can indicate worsening hypertension, which requires immediate intervention to prevent further damage to the kidneys and other organs. Increased fatigue (choice A) is a common symptom in CKD but may not be as acutely concerning as elevated blood pressure. Elevated hemoglobin (choice C) can be an expected outcome of erythropoietin therapy and is not necessarily concerning. Low urine output (choice D) is important to monitor in CKD but may not be as immediately concerning as elevated blood pressure in this context.
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A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnosed osteoporosis. What instruction should the nurse include in the client's teaching plan?
- A. Take on an empty stomach with a full glass of water.
- B. Take with food to avoid stomach upset.
- C. Take before bedtime with a light snack.
- D. Take with milk to enhance absorption.
Correct Answer: A
Rationale: The correct answer is to take alendronate on an empty stomach with a full glass of water. This instruction is essential to ensure proper absorption and prevent esophageal irritation. Taking alendronate with food, before bedtime with a light snack, or with milk can interfere with its absorption and effectiveness, leading to potential side effects or reduced therapeutic benefits.
The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?
- A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
- B. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
- C. Push the undiluted dextrose slowly through the current IV infusion.
- D. Ask the pharmacist to add the dextrose to a TPN solution.
Correct Answer: C
Rationale: The correct immediate intervention by the nurse in this situation is to push the undiluted 50% dextrose slowly through the current IV infusion. This is because in cases of insulin shock, where the client has dangerously low blood sugar levels, administering 50% dextrose directly into the bloodstream helps rapidly increase blood glucose levels. Choice A is incorrect because diluting the dextrose in one liter of normal saline would delay the administration of glucose, which is needed urgently. Choice B is incorrect as mixing the dextrose in a piggyback solution would also delay the administration of the concentrated dextrose. Choice D is incorrect because adding dextrose to a TPN solution is not the immediate intervention needed to address the low blood sugar levels in a client experiencing insulin shock.
The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. She mentions that he was born two weeks after his due date and is a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?
- A. Has your son had any immunizations yet?
- B. Is your son sleepy and difficult to feed?
- C. Are you breastfeeding or bottle feeding your son?
- D. Were any relatives born with birth defects?
Correct Answer: B
Rationale: The correct answer is B. Sleepiness and difficulty feeding are key signs of congenital hypothyroidism, which requires early diagnosis and treatment. Asking about immunizations (choice A) is important but not directly related to assessing hypothyroidism. The feeding method (choice C) is relevant for overall health but not specific to hypothyroidism. Inquiring about relatives with birth defects (choice D) is not the most crucial question to assess hypothyroidism in this scenario.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?
- A. Administer a bronchodilator as prescribed.
- B. Assess the client's respiratory rate.
- C. Assess the client's oxygen saturation.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: Assessing the client's oxygen saturation is crucial in a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. This assessment helps determine if the current oxygen therapy is effective or if adjustments are necessary. While administering a bronchodilator is important in managing COPD, assessing oxygen saturation takes precedence to address the client's immediate oxygen needs. Assessing the respiratory rate is also important but evaluating oxygen saturation provides more direct information about the client's oxygen status. Elevating the head of the bed can improve ventilation but is not the priority when assessing oxygen saturation in a client with COPD receiving supplemental oxygen.
A client with peptic ulcer disease is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?
- A. 'I should avoid drinking alcohol to prevent irritation of my ulcer.'
- B. 'I should take my antacids regularly, even if I don't have symptoms.'
- C. 'I should avoid eating spicy foods to prevent irritation of my ulcer.'
- D. 'I should limit my caffeine intake to prevent irritation of my ulcer.'
Correct Answer: B
Rationale: The statement 'I should take my antacids regularly, even if I don't have symptoms' indicates a misunderstanding. Antacids should only be taken when symptoms are present to neutralize excess stomach acid. Taking antacids regularly when not experiencing symptoms may lead to metabolic alkalosis. Choices A, C, and D are correct statements for a client with peptic ulcer disease as they all focus on avoiding irritants that can exacerbate the condition.