Nokea
The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply.
- A. Check the client for abdominal distention and constipation
- B. Examine the catheter for kinks and obstructions
- C. Contact the client's health care provider
- D. Place the client in a side-lying position
- E. Flush the tubing with dialysate
Correct Answer: A,B,D
Rationale: Checking for distention/constipation (A), examining for catheter issues (B), and repositioning to a side-lying position (D) address common causes of outflow issues non-invasively.
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The client has been vomiting for several days. Which blood gas values is he likely to have?
- A. pH=7.32; CO2=60; HCO3=30
- B. pH=7.32; CO2=33; HCO3=18
- C. pH=7.54; CO2=28; HCO3=22
- D. pH=7.54; CO2=32; HCO3=34
Correct Answer: C
Rationale: Prolonged vomiting causes metabolic alkalosis (high pH, low CO2) due to loss of stomach acid, matching pH=7.54, CO2=28, HCO3=22.
The nurse is collecting data from a 30-month-old client. Which of the following findings would require follow-up?
- A. head circumference has increased by 1 inch (2.5 cm) in the past year
- B. current weight is six times greater than birth weight
- C. nighttime bladder control has not been achieved
- D. anterior and posterior fontanels are both fused
Correct Answer: C
Rationale: Lack of nighttime bladder control at 30 months may indicate developmental delay or medical issues, requiring follow-up to assess for underlying causes.
The nurse prepares to reinforce teaching for a client with latent tuberculosis who is prescribed oral isoniazid. Which instructions should the nurse include? Select all that apply.
- A. Avoid drinking alcohol
- B. Expect body fluids to change color to red
- C. Report yellowing of skin or sclera
- D. Report numbness and tingling of extremities
- E. Take with aluminum hydroxide to prevent gastric irritation
Correct Answer: A,C,D
Rationale: Avoiding alcohol (A), reporting jaundice (C), and reporting neuropathy (D) address isoniazid's risks of hepatotoxicity and peripheral neuropathy.
The nurse is teaching an adult who has a broken ankle that has been casted how to climb stairs. The nurse knows that the client understands how to climb up stairs when she does which of the following?
- A. While bearing weight on the unaffected leg, the client moves the crutches up to the next step followed by the affected leg and then the unaffected leg.
- B. While bearing weight on the unaffected leg, the client moves affected leg to the next step followed by the unaffected leg and the crutches.
- C. While bearing weight on crutches, the client moves the affected leg to the next step followed by the unaffected leg and the crutches.
- D. While bearing weight on crutches, the client moves the unaffected leg to the next step followed by the affected leg and the crutches.
Correct Answer: D
Rationale: To climb stairs, weight is borne on crutches, moving the unaffected leg first, then the affected leg and crutches, ensuring stability and safety using the stronger leg.
The practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse?
- A. Hair loss
- B. Nausea
- C. Petechiae
- D. Stomatitis
Correct Answer: C
Rationale: Petechiae indicate thrombocytopenia, a serious adverse effect of methotrexate, risking bleeding and requiring immediate reporting for dose adjustment or discontinuation.