Nokea
The nurse is caring for a client receiving peritoneal dialysis. Which findings are essential for the nurse to report to the health care provider?
- A. Cloudy outflow
- B. Low-grade fever
- C. Oliguria
- D. Pruritus
- E. Tachycardia
Correct Answer: A,B,E
Rationale: Cloudy outflow (A), fever (B), and tachycardia (E) suggest peritonitis, requiring immediate reporting. Oliguria (C) is expected in renal failure, and pruritus (D) is less urgent.
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The graduate nurse (GN) is caring for a client with a fractured femur in balanced suspension skeletal traction. Which action by the GN will require the precepting nurse to intervene?
- A. Encourages the client to drink plenty of water and choose high-fiber foods from the diet menu
- B. Lifts the traction weights while the unlicensed assistive personnel provide a bed bath and linen change
- C. Monitors the incision and pin insertion sites for erythema, drainage, and malodor
- D. Performs Doppler ultrasound pulse checks in the affected leg every hour for the first 24 hours after surgery
Correct Answer: B
Rationale: Lifting traction weights (B) disrupts alignment and healing, requiring intervention. Hydration and fiber (A), monitoring sites (C), and pulse checks (D) are appropriate.
The nurse has been made aware of laboratory test results for a client who is receiving continuous cardiac monitoring. The client is asymptomatic, and the cardiac monitor shows normal sinus rhythm. Which of the following is most likely an erroneous test result?
- A. BUN of 60 mg/dL (21.4 mmol/L)
- B. serum sodium level of 155 mEq/L (155 mmol/L)
- C. serum potassium level of 7.0 mEq/L (7.0 mmol/L)
- D. serum creatinine level of 4.0 mg/dL (353.6 μmol/L)
Correct Answer: C
Rationale: A potassium level of 7.0 mEq/L (C) is life-threatening and would likely cause arrhythmias, inconsistent with normal sinus rhythm and asymptomatic status, suggesting an error. Elevated BUN (A), sodium (B), and creatinine (D) are concerning but plausible in renal or dehydration issues without immediate cardiac effects.
A 56-year-old client who had a complete hysterectomy 8 months ago is admitted for opiate detoxification. The second day after admission, the client complains of abdominal cramping and sweating. What is the nurse's best response?
- A. Contact the gynecologist for details of the operation
- B. Suspect drug seeking and suggest the client take a walk around the unit
- C. Tell the client she is probably constipated and ask for an order for Milk of Magnesia
- D. Explain to the client that her symptoms are an expected physical response to detoxification and offer comfort medications as ordered
Correct Answer: D
Rationale: Abdominal cramping and sweating are withdrawal symptoms during opiate detoxification, requiring comfort measures and reassurance.
The nurse is reinforcing instructions about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further instruction is needed?
- A. I will always check my blood glucose prior to using the sliding scale.
- B. I will eat breakfast 30 minutes after taking my morning NPH and regular insulin.
- C. I will use a new insulin syringe each time I give myself an injection.
- D. I will use the sliding scale to determine my NPH dose 4 times a day.
Correct Answer: B
Rationale: Eating 30 minutes after NPH and regular insulin (B) risks hypoglycemia, as regular insulin acts within 30 minutes. Checking glucose (A), using new syringes (C), and sliding scale for regular insulin (D) are correct.
A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal when talking to the child's mother?
- A. Teaching the child self care skills
- B. Preparing for independent toileting
- C. Promoting the child's optimal development
- D. Helping the family decide on long term care
Correct Answer: C
Rationale: Promoting the child's optimal development. The primary goal is to promote the child's optimum development.