Nokea
The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding requires immediate intervention?
- A. Increased fatigue
- B. Elevated blood pressure
- C. Headache
- D. Elevated hemoglobin
Correct Answer: A
Rationale: The correct answer is A, 'Increased fatigue.' In a client with CKD receiving erythropoietin therapy, increased fatigue can be a sign of polycythemia, a condition characterized by an elevated red blood cell count. This can lead to increased blood viscosity and raise the risk of thromboembolic events, necessitating immediate intervention. Elevated blood pressure (choice B) is a common concern in CKD but does not require immediate intervention in this context. Headache (choice C) may be related to elevated blood pressure but is not the most critical finding requiring immediate attention. Elevated hemoglobin (choice D) is an expected outcome of erythropoietin therapy and does not require immediate intervention unless excessively high.
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A client with a spinal cord injury at the T1 level is admitted with a suspected deep vein thrombosis (DVT) in the right leg. Which intervention should the nurse implement first?
- A. Administer prescribed anticoagulant therapy
- B. Place the client on bedrest
- C. Elevate the client's right leg
- D. Apply compression stockings to the right leg
Correct Answer: B
Rationale: The correct answer is to place the client on bedrest. Placing the client on bedrest is the priority intervention as it helps prevent the risk of embolization from the DVT, which could lead to a life-threatening pulmonary embolism. Administering anticoagulant therapy, elevating the client's right leg, or applying compression stockings are important interventions in managing DVT but should come after ensuring the client is on bedrest to prevent the dislodgment of the clot.
Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?
- A. Decreased abdominal girth
- B. Increased blood pressure
- C. Clear breath sounds
- D. Decreased serum albumin
Correct Answer: A
Rationale: The correct answer is A: Decreased abdominal girth. In a client with cirrhosis of the liver, a LeVeen shunt is used to treat ascites, which is the accumulation of fluid in the peritoneal cavity. A decrease in abdominal girth indicates that the shunt is effectively draining the ascitic fluid, relieving the client's abdominal distension. Choice B, increased blood pressure, is incorrect as a LeVeen shunt is not expected to impact blood pressure. Choice C, clear breath sounds, is unrelated to the effectiveness of a LeVeen shunt in managing ascites. Choice D, decreased serum albumin, is also not a direct indicator of the shunt's effectiveness in draining ascitic fluid.
A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately. How many ml of fluid intake should the nurse document?
- A. 240 ml
- B. 500 ml
- C. 760 ml
- D. 1000 ml
Correct Answer: C
Rationale: The correct answer is 760 ml. After vomiting 240 ml (1 cup), the nurse should document the remaining 760 ml as the fluid intake. Choice A (240 ml) is the amount vomited, not the total intake. Choice B (500 ml) and Choice D (1000 ml) are the total intake, not considering the vomiting.
The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?
- A. Recommend weight-bearing physical activity.
- B. Encourage a diet high in dairy products.
- C. Suggest vitamin D supplementation.
- D. Advise avoiding caffeine and alcohol.
Correct Answer: A
Rationale: The correct answer is A: Recommend weight-bearing physical activity. Weight-bearing exercises are effective in maintaining bone density and preventing osteoporosis by promoting bone formation. Encouraging a diet high in dairy products (choice B) can provide calcium, but it's not as directly related to bone formation as physical activity. While vitamin D supplementation (choice C) is important for calcium absorption and bone health, it is not directly involved in promoting bone formation. Advising to avoid caffeine and alcohol (choice D) can be beneficial for bone health, but it is not as directly related to promoting bone formation as weight-bearing physical activity.
A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?
- A. White blood cell count of 10,000/mm³
- B. Hemoglobin of 12 g/dL
- C. Liver function tests
- D. Platelet count of 150,000/mm³
Correct Answer: C
Rationale: The correct answer is C: Liver function tests. Methotrexate can cause hepatotoxicity, making it essential to closely monitor liver function tests in clients receiving this medication. Monitoring white blood cell count, hemoglobin, or platelet count is not specifically required for methotrexate therapy and would not provide relevant information regarding potential adverse effects of the medication.