Nokea
The nurse is caring for a 7-year-old client with acute glomerulonephritis. Which of the following is a priority for the nurse to monitor?
- A. Blood pressure
- B. Hematuria
- C. Peripheral edema
- D. Serum lipid levels
Correct Answer: A
Rationale: Hypertension is a priority in glomerulonephritis due to fluid retention, risking complications. Hematuria , edema , and lipids are monitored but less urgent.
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A client is prescribed warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse's discharge instruction?
- A. Maintain a consistent intake of green leafy foods
- B. Report any nose or gum bleeds
- C. Take Tylenol for minor pains
- D. Use a soft toothbrush
Correct Answer: B
Rationale: Report any nose or gum bleeds. The client should notify the health care provider if blood is noted in stools or urine, or any other signs of bleeding occur.
The clinic nurse is reinforcing teaching to a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed?
- A. I will need to get my blood drawn to see if I'm taking the right dose.
- B. I will probably need to take this the rest of my life.
- C. I will take this once a day in the morning.
- D. If this makes my stomach upset, I will take it with an antacid.
Correct Answer: D
Rationale: Antacids reduce levothyroxine absorption, requiring further teaching. Blood monitoring , lifelong use , and morning dosing are correct.
The nurse is providing end-of-life care for a client. The client's spouse is crying and asks the nurse, 'Will you please stay with us?' Which of the following responses would be most appropriate for the nurse to make?
- A. I can come back at the end of my shift when I am able to stay longer.
- B. I will ask a friend or family member to stay with you if you would like.
- C. I can stay and sit with you for a short time if you would like.
- D. I will contact the chaplain to sit with you and your spouse
Correct Answer: C
Rationale: Offering to stay briefly provides immediate comfort while balancing duties. Delaying , delegating to others , or involving a chaplain may not address the spouse's immediate emotional needs.
A client is taking lithium for management of bipolar I disorder. The client's most recent serum lithium level is 0.8 mEq/L (0.8 mmol/L). Based on this result, what prescription does the nurse anticipate receiving from the health care provider?
- A. Continue at the current dose
- B. Decrease the dose
- C. Discontinue the medication
- D. Increase the dose
Correct Answer: D
Rationale: A lithium level of 0.8 mEq/L is low (therapeutic range: 1.0-1.5 mEq/L for acute mania). Increasing the dose is likely to achieve therapeutic levels.
A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which teaching can the nurse reinforce to help the client mobilize secretions and improve sleep? Select all that apply.
- A. Increase fluids to at least 8 glasses (2-3 L) of water a day
- B. Sleep with a cool mist humidifier
- C. Take prescribed guaifenesin cough medicine before bedtime
- D. Use abdominal breathing and the huff cough technique at bedtime
- E. Use pursed lip breathing during the night
Correct Answer: A,B,C,D
Rationale: Fluids , humidifiers , guaifenesin , and huff coughing thin and mobilize secretions. Pursed lip breathing aids exhalation, not secretion clearance.