Nokea
The nurse is caring for a client with a history of chronic kidney disease who is receiving hemodialysis. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Weight gain of 1 kg since last dialysis
- C. Fistula site with a strong thrill
- D. Temperature of 100.8°F (38.2°C)
Correct Answer: D
Rationale: A temperature of 100.8°F suggests infection, a serious complication in hemodialysis patients due to their immunocompromised state and vascular access. Options A, B, and C are normal: BP is stable, 1 kg weight gain is expected fluid retention, and a strong thrill indicates a patent fistula.
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The nurse is teaching a client with a new diagnosis of heart failure about furosemide (Lasix). Which of the following statements by the client indicates a need for further teaching?
- A. I should report muscle cramps to my doctor.
- B. I should take this medication in the morning.
- C. I should eat foods high in potassium.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping furosemide when feeling better is incorrect, as heart failure requires lifelong treatment to manage fluid overload. Options A, B, and C are correct: muscle cramps may indicate hypokalemia, morning dosing minimizes nocturia, and potassium-rich foods are recommended.
The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-hysterectomy complication. Options A, C, and D are normal.
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
- A. right heart function
- B. left heart function
- C. renal tubule function
- D. carotid artery function
Correct Answer: B
Rationale: left heart function. The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).
The nurse is caring for a client with a history of systemic lupus erythematosus.
- A. Which symptom is expected in a client with systemic lupus erythematosus?
- B. Chest pain and shortness of breath.
- C. Fever and joint pain.
- D. Weight gain and edema.
- E. Persistent headaches.
Correct Answer: B
Rationale: Fever and joint pain are common in systemic lupus erythematosus due to autoimmune inflammation. Chest pain may occur with pericarditis, but weight gain and headaches are less specific.
A terminally ill client says to the nurse, 'Do you believe in heaven?' How should the nurse respond?
- A. Yes, I believe in heaven and hell.'
- B. My personal belief is private.'
- C. Do you believe in heaven?'
- D. Do you want to see your clergyman?'
Correct Answer: C
Rationale: Reflecting the question back encourages the client to share beliefs, fostering spiritual discussion. Sharing personal beliefs, withholding, or redirecting are less therapeutic.