Nokea
The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis?
- A. air embolism
- B. clotting of the graft site
- C. dialysis encephalopathy
- D. disequilibrium syndrome
Correct Answer: D
Rationale: Disequilibrium syndrome can occur during hemodialysis due to rapid shifts in fluids and electrolytes, causing symptoms like anxiety, tachypnea, and hypotension.
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The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:
- A. Apply the new tie before removing the old one.
- B. Have a helper present.
- C. Hold the tracheotomy with the nondominant hand while removing the old tie.
- D. Ask the doctor to suture the tracheostomy in place.
Correct Answer: A
Rationale: Applying the new tie before removing the old one ensures the tracheotomy tube remains secure, preventing accidental dislodgement.
A nurse is triaging in the emergency room when a client enters complaining of muscle cramps and a feeling of exhaustion after a running competition. Which of the following would the nurse suspect?
- A. Hypernatremia
- B. Hyponatremia
- C. Syndrome of inappropriate antidiuretic hormone (SIADH)
- D. Decreased potassium
Correct Answer: B
Rationale: Hyponatremia is common in runners due to excessive water intake or sodium loss through sweat, leading to muscle cramps and exhaustion. Hypernatremia, SIADH, or low potassium would present differently.
The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client's plan of care? Select all that apply.
- A. check the dressing every 8 hours for excessive drainage
- B. assess the pupils for signs of increased intracranial pressure
- C. position the client flat with the head rotated away from the surgical site
- D. monitor the client's respiratory status, including rate and pattern of breathing
- E. notify the health care provider if the dressing is saturated or the client has more than 50 mL of drainage in 8 hours
Correct Answer: B, D, E
Rationale: Monitoring pupils, respiratory status, and excessive drainage are critical to detect complications like increased intracranial pressure. Positioning flat is incorrect; the head should be elevated.
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.
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
- A. Wound culture results that show minimal bacteria
- B. Cloudy, foul-smelling urine output
- C. White blood cell count of 14,000
- D. Temperature of 101°F
Correct Answer: A
Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.