Nokea
The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?
- A. Activity tolerance as evidenced by appropriate age-level activities being performed
- B. Absence of skin breakdown as evidenced by intact skin and absence of redness
- C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
- D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr
Correct Answer: D
Rationale: The correct answer is D. In acute glomerulonephritis, the kidneys are inflamed, affecting fluid balance. Monitoring urine output of 1 to 2 ml/kg/hr is crucial to assess kidney function and prevent fluid overload or dehydration. This is the priority outcome as it directly reflects kidney function and overall fluid balance.
A: Activity tolerance is important but not the priority in acute glomerulonephritis.
B: Absence of skin breakdown is important for overall health but not directly related to the condition.
C: Nutritional status is important, but fluid balance takes precedence in managing acute glomerulonephritis.
In summary, maintaining fluid balance is crucial in managing acute glomerulonephritis as it directly reflects kidney function, while the other options are important but not the priority in this scenario.
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A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select one that doesn't apply.)
- A. Increased heart rate
- B. Visual disturbances
- C. Presence of uremic frost
- D. Decreased mentation
Correct Answer: C
Rationale: The correct answer is C: Presence of uremic frost. HHNS is characterized by severe hyperglycemia leading to osmotic diuresis and dehydration, not uremia. A: Increased heart rate is a non-specific sign of stress. B: Visual disturbances can be seen in diabetic retinopathy but are not specific to HHNS. D: Decreased mentation is common in HHNS due to severe dehydration and hyperglycemia leading to altered mental status.
The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?
- A. Perform passive range of motion to the right leg
- B. Remove skeletal weights every shift to assess right leg
- C. Turn frequently from prone to supine positions
- D. Maintain skeletal pin sites and assess for signs of infection
Correct Answer: D
Rationale: The correct answer is D: Maintain skeletal pin sites and assess for signs of infection. This is important to prevent complications like infection, which can be severe. The nurse should regularly assess the pin sites for redness, swelling, or discharge. This intervention ensures early detection and prompt treatment of any signs of infection, reducing the risk of serious complications.
Choice A is incorrect because performing passive range of motion to the right leg may disrupt the traction and interfere with the healing process.
Choice B is incorrect because removing skeletal weights every shift can lead to loss of traction, compromising the fracture alignment and healing process.
Choice C is incorrect because turning the client frequently from prone to supine positions may also disrupt the traction and increase the risk of complications.
The nurse assesses a client who is receiving an infusion of 5% dextrose in water with 20 mEq of potassium chloride. The client has oliguria and a serum potassium level of 6.5 mEq/L. What action should the nurse implement first?
- A. Notify the healthcare provider of the laboratory results
- B. Decrease the rate of the IV infusion
- C. Stop the infusion
- D. Administer sodium polystyrene sulfonate (Kayexalate)
Correct Answer: C
Rationale: The correct action for the nurse to implement first is to stop the infusion (Choice C). Oliguria and a high serum potassium level indicate the client is at risk for hyperkalemia, which can be exacerbated by the potassium chloride infusion. Stopping the infusion is crucial to prevent further elevation of potassium levels and potential cardiac complications.
Choice A (Notify the healthcare provider) is not the first action as immediate intervention is needed to prevent harm. Choice B (Decrease the rate of the IV infusion) is not sufficient to address the immediate risk of hyperkalemia. Choice D (Administer sodium polystyrene sulfonate) is not appropriate as the first action and should only be considered after stabilizing the client's condition.
A client who has had three spontaneous abortions is requesting information about possible causes. The nurse's response should be based on which information?
- A. Chromosomal abnormalities are the most common cause of early spontaneous abortions
- B. Incompetent cervix can cause spontaneous abortions
- C. An infection can cause spontaneous abortions
- D. Nutritional deficiencies are the most common cause of early spontaneous abortions
Correct Answer: A
Rationale: The correct answer is A because chromosomal abnormalities are indeed the most common cause of early spontaneous abortions. These abnormalities can occur during fertilization or early cell division, leading to non-viable embryos. Choice B, incompetent cervix, typically causes late-term miscarriages. Choice C, infections, can contribute to miscarriages but are not the most common cause. Choice D, nutritional deficiencies, can impact pregnancy outcomes but are not the primary cause of early spontaneous abortions. In summary, the correct answer A is supported by the fact that chromosomal abnormalities are the leading cause of early spontaneous abortions, while the other choices are either more relevant to late-term miscarriages or less commonly associated with early pregnancy loss.
The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?
- A. Drink whole milk instead of skim milk to enhance the body's production of amino acids
- B. Take vitamin K 10mg PO daily to enhance production of red blood cells
- C. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
- D. Combine several legumes and grains such as beans and rice to form complete proteins
Correct Answer: D
Rationale: The correct answer is D: Combine several legumes and grains such as beans and rice to form complete proteins. This is the best option because a lacto-vegetarian diet excludes meat but includes dairy products. Legumes and grains complement each other in terms of amino acid profiles, allowing the individual to obtain all essential amino acids needed for protein synthesis. This combination ensures the client gets adequate protein intake necessary for red blood cell production without consuming meat.
A: Drinking whole milk instead of skim milk does not enhance amino acid production. Skim milk contains the same amino acids as whole milk.
B: Taking vitamin K does not enhance red blood cell production. Iron is the key nutrient needed for red blood cell production.
C: Increasing dark yellow vegetables such as carrots does not provide a significant amount of iron to fortify iron stores compared to legumes and grains.