Nokea
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
- A. I'll be sure to rise slowly and sit for a few minutes after lying down.'
- B. I'll be sure to walk at least 2-3 blocks every day.'
- C. I'll be sure to restrict my fluid intake to four or five glasses a day.'
- D. I'll be sure not to take any more aspirin while I am on this drug.'
Correct Answer: A
Rationale: Rising slowly prevents postural hypotension, a common side effect of furosemide that increases fall risk. The other options are not specific to furosemide therapy risks.
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A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
- A. Bleeding, bruising, and hemorrhage
- B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
- C. Pain, pallor, pulselessness, paresthesia, and paralysis
- D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
Correct Answer: C
Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?
- A. D5 in normal saline
- B. D5W
- C. 0.9 normal saline
- D. D5 in lactated Ringer's
Correct Answer: C
Rationale: A concentration of 0.9 NS is used to correct extracellular fluid depletion.
An appropriate nursing intervention for the client with borderline personality disorder is:
- A. Observing the client for signs of depression or suicidal thinking
- B. Allowing the client to lead unit group sessions
- C. Restricting the client's activity to the assigned unit of care throughout hospitalization
- D. Allowing the client to select a primary caregiver
Correct Answer: A
Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.
The nurse is caring for a client with a chest tube. Which observation requires immediate intervention?
- A. The water seal chamber is bubbling continuously.
- B. The drainage system is positioned below the client’s chest.
- C. The chest tube is taped securely to the chest.
- D. The client is lying on the affected side.
Correct Answer: D
Rationale: Lying on the affected side can compress the chest tube, obstructing drainage and risking pneumothorax or tension pneumothorax, requiring immediate repositioning. Continuous bubbling in the water seal is expected initially, and the other findings are appropriate.
A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
- A. Warmed solution helps keep the body temperature maintained within a normal range during instillation
- B. Warmed solution helps dilate the peritoneal blood vessels
- C. Warmed solution decreases the risk of peritoneal infection
- D. Warmed solution promotes a relaxed abdominal muscle
Correct Answer: B
Rationale: Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. Relaxing the abdominal muscles does not facilitate peritoneal dialysis.