The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
- A. Decreased carbohydrates and fat
- B. Decreased sodium and potassium
- C. Increased potassium and protein
- D. Increased sodium and fluids
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
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A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce?
- A. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum)
- B. It is critical to report promptly to your health care provider any findings of peptic ulcers
- C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors
- D. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine
Correct Answer: B
Rationale: It is critical to report promptly to your health care provider any findings of peptic ulcers. Such findings include night-time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite.
When caring for a client with a post-right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote
- A. relaxation and sleep
- B. deep breathing and coughing
- C. incisional healing
- D. range of motion exercises
Correct Answer: B
Rationale: The priority is preventing postoperative respiratory complications. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. Client compliance with recommended deep breathing and coughing exercises will only be achieved with the appropriate pain management.
A nurse is observing a client during an excretory urogram. Which of these observations indicate a complication is occurring?
- A. The client complains of a salty taste in the mouth when the dye is injected.'
- B. The client's entire body turns a bright red color.'
- C. The client states 'I have a feeling of getting warm.''
- D. The client gags and complains 'I am getting sick.''
Correct Answer: B
Rationale: The client's entire body turns a bright red color.' This observation suggests anaphylaxis which results in massive vasodilation. Other findings would be immediate wheezing and/or respiratory arrest.
The HCP documents that the client has a generalized infection. Which specific assessment finding should the nurse expect?
- A. Redness and warmth at the site
- B. Swelling and pain at the site
- C. Hypertension and bradycardia
- D. Fever and widespread muscle aches
Correct Answer: D
Rationale: D: Generalized infections cause systemic symptoms like fever and muscle aches. A, B: These are localized signs. C: Hypotension and tachycardia are more likely.
A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to melt ice chips in the mouth
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Perform frequent oral care with a tooth sponge. Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize.