Nokea
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Pallor and numbness distal to the fistula site
- C. Redness and warmth at the fistula site
- D. Pain in the fistula site
Correct Answer: B
Rationale: The correct answer is B: Pallor and numbness distal to the fistula site. This is indicative of venous insufficiency in a client with an arteriovenous fistula. Venous insufficiency occurs when there is inadequate venous return to the heart, leading to decreased blood flow and oxygen delivery to the tissues. Pallor and numbness are signs of decreased blood flow, which can occur when the fistula is not functioning properly. Cold and numbness (choice A) may indicate arterial insufficiency, not venous. Redness and warmth (choice C) are signs of inflammation, not venous insufficiency. Pain in the fistula site (choice D) may be due to other reasons like infection or nerve compression, not necessarily venous insufficiency.
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A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
- A. Rest frequently throughout the day.
- B. Increase physical activity gradually.
- C. Take medication with meals.
- D. Drink fluids to stay hydrated.
Correct Answer: A
Rationale: The correct answer is A: Rest frequently throughout the day. This is important for a client with hepatitis B to allow the body to heal and conserve energy. Choice B may be harmful as excessive physical activity can strain the liver. Choice C is incorrect as medication for hepatitis B is usually taken on an empty stomach. Choice D is important but not specific to hepatitis B management.
A nurse evaluates a client's PSA lab results. An increase in PSA indicates what condition?
- A. Benign prostatic hyperplasia
- B. Prostatic cancer
- C. Urinary tract infection
- D. Kidney stones
Correct Answer: B
Rationale: The correct answer is B: Prostatic cancer. PSA levels are commonly used as a marker for prostate cancer. Elevated PSA levels indicate an increased likelihood of prostate cancer. Benign prostatic hyperplasia (choice A) is a non-cancerous condition that can also cause elevated PSA levels but is not indicative of cancer. Urinary tract infection (choice C) and kidney stones (choice D) do not directly affect PSA levels. The other choices (E, F, G) are not provided, but the key is to understand that an increase in PSA specifically points towards the possibility of prostatic cancer.
A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?
- A. Serum creatinine
- B. Serum potassium
- C. White blood cell count
- D. Hemoglobin level
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine. Creatinine is a waste product produced by muscles and filtered out by the kidneys. In clients with SLE, renal involvement is common. Elevated serum creatinine levels indicate impaired renal function, as the kidneys are not effectively filtering out waste products. Monitoring serum creatinine levels helps assess renal function and detect kidney damage early.
Choices B, C, D, and E are incorrect as they do not directly reflect renal function. Serum potassium levels (B) are more indicative of electrolyte balance, white blood cell count (C) indicates immune response, and hemoglobin level (D) reflects oxygen-carrying capacity.
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
- A. Fresh flowers and potted plants in the room
- B. Visitors from outside the hospital
- C. Foods high in vitamin C
- D. A humidifier in the room
Correct Answer: A
Rationale: The correct answer is A: Fresh flowers and potted plants in the room. Neutropenic clients are at high risk for infections due to low white blood cell count. Fresh flowers and potted plants can harbor bacteria and fungi, increasing the risk of infection. Restricting these items helps minimize exposure to pathogens. Choices B and D are incorrect as long as visitors are screened for infections and the humidifier is cleaned regularly. Choice C, foods high in vitamin C, is incorrect as these foods can actually help boost the immune system.
A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching?
- A. Practice effective hand hygiene.
- B. Limit physical activity.
- C. Use antiseptic mouthwash.
- D. Avoid drinking water.
Correct Answer: A
Rationale: The correct answer is A: Practice effective hand hygiene. This is crucial in preventing transmission of hepatitis A, which is primarily spread through fecal-oral route. Handwashing with soap and water can remove the virus from hands. Limiting physical activity (B) and using antiseptic mouthwash (C) are not effective in preventing transmission. Avoiding drinking water (D) is not necessary unless the water source is contaminated.