Nokea
The nurse is caring for a client receiving peritoneal dialysis. Which of the following assessment findings would require an intervention by the nurse?
- A. Abdominal discomfort during infusion of dialysate.
- B. Presence of constipation.
- C. Cloudy dialysate output.
- D. Ecchymosis around peritoneal catheter.
Correct Answer: C
Rationale: indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity
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When drawing up a dosage of subcutaneous heparin, how much air should be drawn into the syringe after the correct dosage is obtained?
- A. 1 mL
- B. 0.6 mL
- C. 0.2 to 0.3 mL
- D. 0.01 mL
Correct Answer: C
Rationale: An air lock of 0.2-0.3 mL (C) is used in subcutaneous heparin injections to ensure the full dose is delivered and to prevent leakage.
The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:
- A. 30 minutes before meals
- B. With each meal
- C. In a single dose at bedtime
- D. 60 minutes after meals
Correct Answer: C
Rationale: Ranitidine is most effective when taken at bedtime to suppress nocturnal acid production in erosive gastritis.
The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates the client understands his new diet?
- A. Cornflakes, whole milk, banana, and coffee
- B. Scrambled eggs, bacon, toast, and coffee
- C. Oatmeal, apple juice, dry toast, and coffee
- D. Pancakes, ham, tomato juice, and coffee
Correct Answer: C
Rationale: Oatmeal, apple juice, and dry toast are low in sodium and saturated fat, aligning with a DASH diet for hypertension management.
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
- A. Withholding all morning medications
- B. Ordering a CBC and CPK
- C. Administering prescribed anti-Parkinsonian medication
- D. Transferring the client to a medical unit
Correct Answer: D
Rationale: Severe muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a medical emergency requiring immediate transfer to a medical unit for treatment.
The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:
- A. Change the nursing assistant's assignment
- B. Explore the interaction with the nursing assistant
- C. Discuss the matter with the client's family
- D. Initiate a group session with the nursing assistant
Correct Answer: B
Rationale: Exploring the interaction addresses the behavior appropriately.