Nokea
The nurse is monitoring a client during the dwell time of a peritoneal dialysis cycle. Which of the following findings would require immediate follow-up?
- A. reports of intermittent nausea
- B. crackles in the lung bases bilaterally
- C. 1+ pitting edema of the ankles and feet bilaterally
- D. blood pressure of 108/88 mm Hg and heart rate of 72/min
Correct Answer: B
Rationale: Crackles suggest fluid overload, a serious dialysis complication. Nausea , mild edema , and normal BP/HR are less urgent.
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A woman who is at 39 weeks gestation enters the hospital in early labor. Several hours later, she says, 'What's happening? I suddenly feel as though I have to have a bowel movement.' The woman starts bearing down as if to push out stool. What is the best initial action for the licensed practical nurse at this time?
- A. Encourage her to push
- B. Ask her to pant
- C. Immediately call the charge nurse
- D. Ask her when she last had a bowel movement
Correct Answer: B
Rationale: The urge to have a bowel movement and bearing down indicate advanced labor or delivery. Panting prevents pushing, allowing time to assess and prepare for delivery.
The nurse has taught the parents of a 6-year-old client with cystic fibrosis who has a prescription for pancreatic enzymes. Which of the following statements by a parent would require follow-up?
- A. It is acceptable for my child to chew the medication before swallowing it
- B. I should give the medication with or just before my child has a meal or snack
- C. I need to monitor the total amount of medication that I give to my child every day.
- D. It is acceptable to open the capsule and sprinkle the medication on a tablespoon of applesauce.
Correct Answer: A
Rationale: Chewing pancreatic enzymes destroys the enteric coating, reducing efficacy. Timing with meals , monitoring doses , and sprinkling on applesauce are correct practices.
The nurse is feeding a client who experienced a right-sided stroke and has dysphagia and hemianopsia. Which of the following actions would be appropriate for the nurse to take? Select all that apply.
- A. Encourage the client to turn the head to the left occasionally while eating
- B. Add milk to the client's mashed potatoes to make the consistency thinner.
- C. Provide a straw for the client to use while drinking a fruit smoothie.
- D. Place food on the stronger side of the client's mouth
- E. Assist the client to sit in an upright position.
Correct Answer: D,E
Rationale: Placing food on the stronger side and upright positioning reduce aspiration risk. Head turning may not help right-sided stroke, thinning food increases aspiration, and straws are unsafe.
The practical nurse is collaborating with the registered nurse to develop a care plan for a homeless client just brought into the emergency department with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply.
- A. Apply occlusive dressings after rewarming
- B. Elevate affected extremities after rewarming
- C. Massage the areas to increase circulation
- D. Provide adequate analgesia
- E. Provide continuous warm water soaks
Correct Answer: B,D
Rationale: Elevation reduces swelling post-rewarming. Analgesia manages pain. Occlusive dressings trap moisture, massaging risks tissue damage, and continuous soaks may cause maceration.
A client scheduled for a femoral popliteal bypass is to be assigned to a semi-private room. Which client would be the most suitable roommate for the client with a femoral popliteal bypass graft?
- A. A client with a pituitary tumor
- B. A client with respiratory sarcoidosis
- C. A client with a diabetic ulcer
- D. A client with a closed fracture of femur
Correct Answer: A
Rationale: The client with a pituitary tumor is the most suitable roommate as they are unlikely to have an infectious condition or mobility issues that could complicate recovery. Respiratory sarcoidosis may involve respiratory issues, increasing infection risk. A diabetic ulcer poses an infection risk due to potential open wounds. A closed femur fracture may involve similar mobility restrictions, complicating room logistics.