Nokea
The nurse is caring for a 28-year-old female with a long history of heroin addiction. The client tells the nurse that she started off using a small amount recreationally, but as time went on, she needed more and more heroin to feel a high. The nurse recognizes this as
- A. addiction.
- B. dependence.
- C. tolerance.
- D. withdrawal.
Correct Answer: C
Rationale: Tolerance is the need for increasing doses to achieve the same effect, as described in the client’s heroin use.
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The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
- A. Document the finding
- B. Send a specimen to the lab
- C. Strain the urine
- D. Obtain a complete blood count
Correct Answer: B
Rationale: Cloudy dialysate suggests peritonitis, requiring lab analysis.
The nurse is caring for a client with end-stage kidney disease. The client says, 'I have decided that I don't want any more dialysis or treatments. This is just prolonging the inevitable.' The nurse responds, 'You have every right to do so. I will notify the nephrologist of your wishes.' Which ethical principle is being demonstrated by the nurse?
- A. justice
- B. fidelity
- C. autonomy
- D. beneficence
Correct Answer: C
Rationale: Respecting the client’s decision to refuse treatment demonstrates autonomy, prioritizing their right to self-determination.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:
- A. Additional calcium in the infant's diet
- B. Careful handling to prevent fractures
- C. Providing extra sensorimotor stimulation
- D. Frequent testing of visual function
Correct Answer: B
Rationale: Osteogenesis imperfecta causes brittle bones, so careful handling is critical to prevent fractures in infants with this condition.
A client has recurrent episodes of constipation and fecal impaction. The nurse is assisting the client with a bowel-training regimen. Which of the following interventions should be included? Select all that apply.
- A. Scheduled toileting
- B. Stool softeners
- C. High-fiber diet
- D. Daily laxatives
- E. Periodic enemas
- F. Routine exercise
Correct Answer: A,B,C,F
Rationale: Bowel training includes scheduled toileting (A), stool softeners (B), high-fiber diet (C), and routine exercise (F) to promote regular bowel movements. Daily laxatives (D) and periodic enemas (E) are not preferred long-term.
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
- A. Elevate the head
- B. Recheck the O2 saturation in 30 minutes
- C. Apply oxygen by mask
- D. Assess the heart rate
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.