Nokea
The nurse is caring for a client with a history of chronic kidney disease who is receiving hemodialysis. Which of the following findings would require immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Weight gain of 1 kg since last dialysis.
- C. Bright red blood in the dialysis tubing.
- D. Potassium level of 4.5 mEq/L.
Correct Answer: C
Rationale: Bright red blood in the dialysis tubing indicates a potential access site bleed or tubing disconnection, requiring immediate intervention to prevent blood loss. Mild hypertension (A) and weight gain (B) are common, and a normal potassium level (D) is unremarkable.
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The client states, 'My discharge plan leaves me with a lot to do. I don't think I can do it. I'm never good at doing things.' The nurse knows the client lacks:
- A. maturation.
- B. organization.
- C. readiness to learn.
- D. self-efficacy.
Correct Answer: D
Rationale: Expressing doubt in ability to manage the discharge plan indicates low self-efficacy, a belief in one's capacity to execute tasks.
Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
- A. open leg fracture
- B. open head injury
- C. stab wound to the chest
- D. traumatic amputation of a thumb
Correct Answer: C
Rationale: A stab wound to the chest is the highest priority due to potential for pneumothorax or mediastinal shift, which can be life-threatening. The ABC (airway, breathing, circulation) principle prioritizes this injury. Physiological Adaptation
A nurse is assessing a newborn who is 1 hour old. Which of the following findings should be reported to the healthcare provider? (Select all that apply)
- A. Respiratory rate of 50 breaths per minute
- B. Nasal flaring
- C. Grunting
- D. Temperature of 36.5°C (97.7°F)
Correct Answer: B,C
Rationale: Nasal flaring and grunting indicate respiratory distress, requiring immediate reporting. A respiratory rate of 50 and temperature of 36.5°C are normal for a newborn.
The patient with DM has flu.
Which nursing action is more appropriate?
- A. Frequent monitoring of blood glucose.
- B. Expected increase in the patient insulin requirement.
- C. Implement respiratory isolation.
- D. Monitor the patient's respiratory status frequently.
Correct Answer: A
Rationale: Flu can disrupt glucose control, making frequent monitoring critical.
The patient is admitted to the emergency department and was brought to the unit due to poor diabetic management. The wife asks how they can learn better. They have previously been to a diabetic class without much success.
Which of the following nursing strategy will be appropriate for the client?
- A. Arrange a meeting with the health care team.
- B. Have a one-on-one diabetic teaching with the client.
- C. Refer the client and wife to group diabetic teaching class.
- D. Discuss the possibility of having to stay longer in the unit to manage the blood sugar.
Correct Answer: B
Rationale: One-on-one teaching allows tailored education to address specific learning needs.