Nokea
The nurse is monitoring a client with a diagnosis of chronic kidney disease (CKD). Which assessment finding should the nurse report to the primary health care provider?
- A. Pallor
- B. Fatigue
- C. Lethargy
- D. Petechiae
Correct Answer: D
Rationale: CKD can cause damage to many body systems. Hematological manifestations that can occur with this disease include anemia and bleeding. Abnormal bleeding (petechiae; purpura; bruising; bleeding from the mucous membranes, nose, or gums; vaginal bleeding; or intestinal bleeding) should be reported to the primary health care provider because it can be life-threatening. Pallor, fatigue, and lethargy are clinical manifestations associated with anemia.
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A client with iron deficiency anemia is taking iron supplements. The nurse emphasizes to the client that the drug will have increased absorption if taken with:
- A. Milk
- B. Orange juice
- C. Food
- D. Beta-carotene
Correct Answer: B
Rationale: Iron absorption is enhanced by vitamin C, found in orange juice, while milk and food can decrease absorption. Beta-carotene does not significantly affect iron absorption.
The nurse is monitoring the function of a client's chest tube that is attached to a chest drainage system. The nurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What should the nurse determine based on this finding?
- A. There is a leak in the system.
- B. Suction should be added to the system.
- C. This is caused by client pneumothorax.
- D. Water should be added to the chamber.
Correct Answer: D
Rationale: The water-seal chamber should be filled to the 2-cm mark to provide an adequate water seal between the external environment and the client's pleural cavity. The water seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding sterile water until the level is again at the 2-cm mark. The other interpretations are incorrect.
A client with a history of heart failure is prescribed spironolactone (Aldactone). Which electrolyte imbalance should the nurse monitor for?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring to prevent arrhythmias.
Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation exercise program. The client is a diabetic and has bilateral leg discomfort with walking. The nurse should advise the client to exercise using a stationary bicycle and intermittent training because of the client's:
- A. Diabetic neuropathy
- B. Muscle atrophy
- C. Raynaud's disease
- D. Transient ischemic attacks
Correct Answer: A
Rationale: Diabetic neuropathy likely causes the client's leg discomfort, making low-impact, intermittent stationary cycling suitable to avoid exacerbating symptoms. Other conditions are less likely causes.
The nurse is caring for a client who has just undergone a tonsillectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage frequent swallowing.
- B. Monitor for excessive swallowing.
- C. Offer ice chips immediately.
- D. Keep the head of the bed flat.
Correct Answer: B
Rationale: Monitoring for excessive swallowing is critical post-tonsillectomy, as it may indicate bleeding from the surgical site.