Nokea
The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. The effects of diminished renal perfusion will have which physiologic response?
- A. Diuresis
- B. Increased fluid retention
- C. Elevated bicarbonate level
- D. Paroxysmal idiopathic narcosis
Correct Answer: B
Rationale: When there is diminished renal perfusion due to decreased cardiac output, the kidneys receive less blood flow. This leads to a decrease in urine output and an increase in fluid retention, as the kidneys are not able to effectively filter and excrete excess fluid. Elevated bicarbonate level and paroxysmal idiopathic narcosis are not typically associated with diminished renal perfusion in heart failure. Therefore, the correct answer is 'Increased fluid retention.'
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The nurse is caring for a client complaining of intense headaches with increasing pain for the past one month. An MRI is ordered. In reviewing the client's information, which piece of information is of concern?
- A. Allergy to shellfish
- B. Has a cardiac pacemaker
- C. A diabetic
- D. No IV access
Correct Answer: B
Rationale: The correct answer is 'Has a cardiac pacemaker.' If a client with a cardiac pacemaker undergoes an MRI, the magnetic field can interfere with the pacemaker's function, leading to serious complications or even death. It is crucial to ensure that the pacemaker is compatible with MRI imaging or to consider alternative imaging modalities. The other choices, such as 'Allergy to shellfish,' 'A diabetic,' and 'No IV access,' are not direct contraindications for an MRI scan and do not pose the same level of risk as having a cardiac pacemaker.
The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
- A. Lifting the affected leg with the palms of the hand
- B. Covering the affected leg with a blanket to avoid chills
- C. Placing plastic over the groin prior to bathing
- D. Elevating the cased leg on two pillows
Correct Answer: B
Rationale: The correct answer is covering the affected leg with a blanket to avoid chills. Covering the leg with a blanket can prevent the evaporation of heat from the new cast, which can lead to skin irritation or discomfort. Lifting the affected leg with the palms of the hand is appropriate as it helps in providing support and prevents unnecessary pressure on the cast. Placing plastic over the groin prior to bathing is also acceptable to protect the area from getting wet. Elevating the cased leg on two pillows helps reduce swelling and promotes circulation, making it a suitable action.
A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).
- A. Weight gain
- B. Fatigue
- C. Bloody sputum
- D. Diaphoresis during sleep
Correct Answer: A
Rationale: The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.
What essential assessment must be performed for clients with implanted dialysis access devices?
- A. Color and capillary refill
- B. Patency and pulse
- C. Thrill and bruit
- D. Trousseau's and temperature
Correct Answer: C
Rationale: Correct! When assessing clients with implanted dialysis access devices, it is crucial to palpate for the thrill, which indicates blood flow, and auscultate for the bruit, a humming sound, to ensure the patency of the access device. Choices A, B, and D are incorrect as they are not specific assessments related to dialysis access devices. Checking color and capillary refill, pulse, Trousseau's sign, and temperature are important assessments in other contexts but not specifically for monitoring implanted dialysis access devices.
While performing wound care to a donor skin graft site, the nurse notes some scabbing at the edges and a black collection of blood. What is the nurse's next action?
- A. Leave the scabbed area alone and apply extra ointment
- B. Notify the physician
- C. Gently remove the debris and re-dress the wound
- D. Apply skin softening lotion for 3 hours and then re-dress
Correct Answer: C
Rationale: When the nurse notes scabbing at the edges and a black collection of blood, it indicates the presence of debris that needs to be addressed. Leaving the scabbed area alone and applying extra ointment may not address the underlying issue and could lead to complications. Notifying the physician is important in some cases, but immediate action is required to prevent infection in this situation. Gently removing the debris and re-dressing the wound is the correct course of action to promote healing and prevent complications.