Nokea
The nurse performs an assessment during a fluid exchange for the client who is 48 hours post-insertion of an abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the appearance of which of the following needs to be reported to the provider immediately?
- A. slight pink-tinged drainage
- B. abdominal discomfort
- C. muscle weakness
- D. cloudy drainage
Correct Answer: D
Rationale: Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation of the peritoneum). The other options are expected side effects of peritoneal dialysis.
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The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?
- A. Impaired skin integrity related to dependent edema
- B. Activity intolerance related to oxygen supply and demand imbalance
- C. Constipation related to immobility
- D. Risk for infection related to ineffective mobilization of secretions
Correct Answer: B
Rationale: Activity intolerance related to oxygen supply and demand imbalance. This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen, leading to findings of dyspnea and fatigue.
The nurse is caring for a client who has congestive heart failure. Which finding indicates that her condition is getting worse?
- A. An increase in urine output
- B. A decrease in blood pressure
- C. A decrease in heart rate
- D. Warm, moist skin
Correct Answer: B
Rationale: A decrease in blood pressure suggests worsening cardiac output in congestive heart failure, indicating decompensation.
The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse
- A. verifies that gel is present on each electrode and is not dried out
- B. cleanses and dries the skin before placing the electrodes on the client
- C. clips excessive hair off the client before applying the electrodes
- D. places one electrode each on the client's upper and lower extremities
Correct Answer: D
Rationale: Placing electrodes on extremities (D) is incorrect for cardiac monitoring, which requires chest placement. Verifying gel (A), cleansing skin (B), and clipping hair (C) are appropriate.
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidyl glycerol is noted. The nurse's assessment of this data is:
- A. The infant is at low risk for congenital anomalies.
- B. The infant is at high risk for intrauterine growth retardation.
- C. The infant is at high risk for respiratory distress syndrome.
- D. The infant is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 and presence of phosphatidyl glycerol suggest immature lungs, indicating a high risk for respiratory distress syndrome, so C is correct. Answers A, B, and D are not directly related to these findings.
The nurse is caring for a frail elderly client in her home. Which behavior, if observed or reported, should the nurse report to the supervisor for further evaluation of possible abuse?
- A. The client's daughter is attempting to be declared her mother's legal guardian.
- B. The client is frequently left in bed alone in the house for several hours at a time.
- C. The client has brown spots on her arms.
- D. The client says, 'My daughter doesn't like me very much. She yells at me.'
Correct Answer: B
Rationale: Leaving a frail client alone for hours poses neglect risk, warranting abuse evaluation. Guardianship, brown spots, or yelling are less definitive without context.