Nokea
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
- A. Observe for edema proximal to the site
- B. Irrigate with 5 ml of 0.9% Normal Saline
- C. Palpate for a thrill over the fistula
- D. Check color and warmth in the extremity
Correct Answer: C
Rationale: Palpate for a thrill over the fistula. A thrill indicates patency of the fistula.
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An elderly client is admitted to a skilled nursing care facility. When doing a skin assessment, the nurse notes a 3-cm round area of partial-thickness skin loss that looks like a blister on the client's sacrum. The nurse interprets this to be a:
- A. stage I pressure ulcer.
- B. stage II pressure ulcer.
- C. stage III pressure ulcer.
- D. stage IV pressure ulcer.
Correct Answer: B
Rationale: A stage II pressure ulcer involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer, matching the description. Stage I is non-blanchable erythema, stage III involves full-thickness loss, and stage IV extends to muscle/bone.
A client with chronic bronchitis is admitted with complaints of chest pain. Which of the following drug orders should the nurse question?
- A. Nitroglycerin (Nitrostat)
- B. Cephalexin (Keflex)
- C. Propranolol (Inderal)
- D. Verapamil (Calan)
Correct Answer: C
Rationale: Propranolol, a beta-blocker, can exacerbate bronchoconstriction in chronic bronchitis, worsening respiratory symptoms. Nitroglycerin, cephalexin, and verapamil are less likely to pose issues in this context.
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions should the nurse prioritize?
- A. Encourage early ambulation.
- B. Administer pain medication as needed.
- C. Keep the affected leg in adduction.
- D. Monitor the incision for drainage.
Correct Answer: A
Rationale: Early ambulation prevents complications like thrombosis and promotes recovery. Options B, C, and D are secondary or incorrect.
An adult male had a myocardial infarction six weeks ago. He asks the nurse if it is safe for him to have sex. What should the nurse include when replying?
- A. Taking nitroglycerin before sexual activity is often helpful.
- B. Taking drugs for erectile dysfunction in addition to nitroglycerin is advised.
- C. The client should rest for several hours before engaging in sexual activity.
- D. Sexual activity should be avoided for six months after a heart attack.
Correct Answer: A
Rationale: Nitroglycerin before sexual activity can prevent angina, and sexual activity is generally safe 6 weeks post-MI if the patient is stable.
The nurse is caring for a client with a history of chronic kidney disease.
- A. Which dietary restriction is most important for a client with chronic kidney disease?
- B. Low-sodium diet.
- C. Low-carbohydrate diet.
- D. High-protein diet.
- E. High-fat diet.
Correct Answer: A
Rationale: A low-sodium diet reduces fluid retention and hypertension in chronic kidney disease. Protein is restricted, carbohydrates are encouraged, and high-fat diets are not indicated.