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The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan?
- A. Restrict fluids to 1,000 mL/24 hours.
- B. Drink 400 to 500 mL with each meal.
- C. Drink fluids midmorning, midafternoon, and late afternoon.
- D. Attempt to void at least every 2 hours.
- E. Use intermittent catheterization as needed.
Correct Answer: B,C,D,E
Rationale: Drinking 400-500 mL with meals (B), timing fluids (C), voiding every 2 hours (D), and using intermittent catheterization (E) promote bladder control. Restricting fluids to 1,000 mL/day risks dehydration and is inappropriate.
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The nurse is caring for a client receiving a unit of packed red blood cells (PRBCs). The client reports chills, and their oral temperature is 103° F (39.4° C). Which action should the nurse take first?
- A. Assess the client's blood pressure and heart rate
- B. Obtain blood cultures
- C. Pause the transfusion
- D. Notify the primary healthcare provider (PHCP)
Correct Answer: C
Rationale: Chills and a fever of 103°F during a PRBC transfusion suggest a possible febrile or hemolytic reaction. The first action is to pause the transfusion to prevent further administration of potentially problematic blood. Assessing vital signs, obtaining cultures, and notifying the provider follow after stopping the transfusion.
The nurse should assess an older adult with macular degeneration for:
- A. Loss of central vision.
- B. Loss of peripheral vision.
- C. Total blindness.
- D. Blurring of vision.
Correct Answer: A
Rationale: Macular degeneration primarily affects the macula, leading to loss of central vision, which impairs activities like reading and recognizing faces.
A client with rheumatoid arthritis states, 'I can't do my household chores without becoming tired. My knees hurt whenever I walk.' Which nursing diagnosis would be most appropriate?
- A. Activity intolerance related to fatigue and pain.
- B. Self-care deficit related to increasing joint pain.
- C. Selective coping related to chronic pain.
- D. Disturbed body image related to fatigue and joint pain.
Correct Answer: A
Rationale: The client's symptoms of fatigue and knee pain directly contribute to activity intolerance, making this the most appropriate nursing diagnosis.
The nurse is preparing to administer medication to a client. After verifying the right medication, dose, route, and time, the nurse should
- A. confirm the client's identity using two client identifiers.
- B. explain the purpose and potential side effects of the medication to the client.
- C. ensure the medication is within its expiration date.
- D. document the medication administration in the client's medical record.
Correct Answer: A
Rationale: Confirming client identity is the next step after verifying medication details to ensure safety.
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate?
- A. A gelatin dessert.
- B. Yogurt.
- C. An orange.
- D. Peanuts.
Correct Answer: A
Rationale: Gelatin dessert is low in potassium, suitable for a client with hyperkalemia, unlike yogurt, oranges, or peanuts.