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The physician has ordered a low-potassium diet for a client. Which of the following food choices indicates that the client needs further instruction regarding the diet?
- A. Apple.
- B. Baked potato.
- C. Carrots.
- D. Spinach.
Correct Answer: B
Rationale: Baked potatoes are high in potassium, so choosing them indicates a need for further teaching on a low-potassium diet.
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Select the complication of intravenous therapy that is accurately paired with one of its interventions.
- A. Infection: Lowering the limb to promote circulation
- B. Infiltration: The application of cold to the site
- C. Extravasation: The aspiration of contents including blood from the IV cannula
- D. Hematoma: The administration of dexrazoxane
Correct Answer: C
Rationale: Aspirating contents from the IV cannula is an intervention for extravasation to remove vesicant drugs and minimize tissue damage.
The nurse has done preoperative teaching with a client scheduled for percutaneous insertion of an inferior vena cava (IVC) filter. Which client statement indicates the need for further teaching about the procedure?
- A. This is done under general anesthesia.
- B. This procedure is rarely associated with complications.
- C. It may cause congestion when clots get trapped at the filter.
- D. This could possibly eliminate the need for anticoagulant therapy.
Correct Answer: A
Rationale: The percutaneous approach uses local anesthesia. Complications after insertion of an IVC filter are rare. When they do occur, they include air embolism, improper placement, and filter migration. Venous congestion can occur from accumulation of thrombi on the filter, but the process usually occurs gradually. There is usually no need for anticoagulant therapy after surgery.
Which test result should the nurse review to determine the compatibility of blood from two different donors?
- A. Rh factor
- B. ABO typing
- C. Direct Coombs'
- D. Indirect Coombs'
Correct Answer: D
Rationale: The indirect Coombs' test detects circulating antibodies against red blood cells (RBCs) and is the screening component of a prescription to 'type and screen' a client's blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The Rh factor is determined at the same time as the ABO type. The direct Coombs' test is used to detect idiopathic hemolytic anemia by detecting the presence of autoantibodies against the client's RBCs.
A client with a history of liver cirrhosis is admitted with ascites. The nurse should monitor the client for which of the following complications?
- A. Hypotension.
- B. Respiratory distress.
- C. Hyperkalemia.
- D. Hypoglycemia.
Correct Answer: B
Rationale: Ascites can compress the diaphragm, leading to respiratory distress, a complication the nurse should monitor for in cirrhosis.
You are serving as the supervisory nurse for a home healthcare agency in the community. You are doing an admission assessment for a 76 year old male client who resides with his elderly wife. Which of the following assessments would indicate that the couple needs some education relating to home safety?
- A. The client has refrigerated foods labelled with an expiration date.
- B. You assess that the home is free of scatter rugs that many use to protect the feet against hard floors.
- C. The client uses the FIFO method for insuring food safety.
- D. The client assures you that the smoke alarm batteries are replaced annually to insure that they work.
Correct Answer: B
Rationale: The absence of scatter rugs is a safety feature, not a concern requiring education. Labeled foods , FIFO method , and annual smoke alarm battery replacement are all safe practices. However, the question implies a need for education, and B is the least directly related to a safety deficit, but no clear safety issue is present in the options provided.