Nokea
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Increase Intake of potassium rich foods such as bananas or cantaloupe.
- B. Restrict protein intake by limiting meats and other high protein foods.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of high fiber foods, such as bran cereal.
Correct Answer: B
Rationale: Restricting protein reduces kidney workload and proteinuria, preserving function in glomerulonephritis.
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After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Increased temperature to lower extremity.
- B. Circumferential edema of right foot.
- C. Right foot pale with sluggish capillary refill.
- D. Reports throbbing right leg pain.
Correct Answer: C
Rationale: Pale foot with sluggish capillary refill indicates compromised circulation, risking tissue ischemia requiring urgent intervention.
While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
- A. Hematocrit.
- B. Platelet count.
- C. White blood cell (WBC) count.
- D. Blood pH level.
Correct Answer: C
Rationale: WBC count indicates infection, as purulent drainage suggests bacterial colonization requiring prompt intervention.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Do your family members share combs and brushes?
- B. Do you have any dry patches on your feet and hands?
- C. Has everyone at home already had varicella?
- D. Have the antifungal creams been effective?
Correct Answer: C
Rationale: Asking about varicella history assesses the risk of chickenpox transmission to susceptible household members from herpes zoster.
History and Physical
Nurses’ notes
Laboratory Results
Flow Sheet
The nurse is caring for a client who was admitted to the hospital with reports of shortness of breath, fever, fatigue, and oral thrush three days ago. The health care provider reviews the laboratory and diagnostic tests with the client and informs of the diagnosis of Pneumocystis pneumonia. The client reports that they recently tested HIV positive. The nurse reviews the client's medical record.
HIV diagnosed 4 months ago with no medications prescribed.
Note added to H&P reporting client wishes to be confidential since family and friends are unaware of the HIV diagnosis
What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.
- A. Administer antiemetic
- B. Monitor for adverse reaction to antibiotics
- C. Increase IV fluids to 150 mL/hr
- D. Initiate airborne isolation
- E. Repeat CD4+ T-cell count STAT
Correct Answer: A,B,C
Rationale: Antiemetics , antibiotic monitoring , and increased fluids address emesis, treatment safety, and hydration in Pneumocystis pneumonia.
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
- A. Educate client on signs and symptoms of narcotic dependency.
- B. Administer opioid and non-opioid medication simultaneously.
- C. Give maximum dosage when score reaches 10.
- D. Alternate IV and IM analgesic medications.
Correct Answer: B
Rationale: Combining opioid and non-opioid medications provides synergistic pain relief, optimizing control while minimizing opioid side effects.