Nokea
The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which intervention should be assigned to the LPN?
- A. Assessment of the client who has had a Kock pouch procedure.
- B. Monitoring of the postop client with a WBC of 22,000/mm3.
- C. Administration of the prescribed antineoplastic medications.
- D. Care for the client going for an MRI of the kidneys.
Correct Answer: D
Rationale: Caring for a client going for an MRI involves routine tasks (e.g., transport, preparation) within an LPN’s scope. Assessment, monitoring high WBC, and administering chemotherapy require RN judgment.
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Before peritoneal dialysis begins, the nurse correctly informs the client that the procedure involves the movement of urea and creatinine through the peritoneum by which means?
- A. Osmosis
- B. Diffusion
- C. Filtration
- D. Gravity
Correct Answer: B
Rationale: Diffusion is the primary mechanism by which urea and creatinine move across the peritoneal membrane during dialysis.
The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first?
- A. The client who has hemoglobin of 9.8 g/dL and hematocrit of 30%.
- B. The client who does not have a palpable thrill or auscultated bruit.
- C. The client who is complaining of being exhausted and is sleeping.
- D. The client who did not take antihypertensive medication this morning.
Correct Answer: B
Rationale: Absence of a thrill or bruit indicates a non-functioning dialysis access (e.g., AV fistula), which is critical for dialysis and requires immediate assessment to prevent treatment delays or complications. Anemia, exhaustion, or missed medication are less urgent.
As the nurse instructs the client about CBI, which information should the nurse provide? Select all that apply.
- A. You may feel the urge to urinate even though the bladder is empty.
- B. Do not to try to urinate around the catheter, because this will cause bladder spasms.
- C. You need to limit your fluids to 4 glasses per day.
- D. It is normal for the urine to be bloody immediately after surgery.
- E. The catheter will be removed in about a week.
- F. By the time you are ready to go home, your urine should be pink with a few clots.
Correct Answer: A,B,D,F
Rationale: These statements accurately describe CBI effects, expectations, and precautions post-TURP.
In evaluating multiple clients with UTIs, the clinic nurse should identify which client to be at least risk for developing a UT1?
- A. A client with urethral mucosa damage
- B. A client with an altered mental condition
- C. A client with an altered metabolic state
- D. An immunocompromised client
Correct Answer: C
Rationale: An altered metabolic state, without specific risk factors like diabetes, poses the least risk for UTIs compared to mucosal damage, mental status changes, or immunosuppression.
The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?
- A. Start a new IV in the right hand.
- B. Discontinue the intravenous line.
- C. Complete an incident record.
- D. Place a warm washrag over the site.
Correct Answer: B
Rationale: Tenderness and a red streak indicate phlebitis or infection. Discontinuing the IV line prevents further complications. Starting a new IV, completing an incident report, or applying warmth are secondary actions.