Nokea
What are the key nursing interventions for a patient undergoing dialysis?
- A. Monitor fluid balance and administer heparin
- B. Monitor blood pressure and prevent clot formation
- C. Administer medications and monitor blood chemistry
- D. Provide dietary education and encourage protein intake
Correct Answer: A
Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.
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A client has developed phlebitis at the IV site. What is the next step the nurse should take?
- A. Administer an anti-inflammatory medication
- B. Discontinue the IV and notify the provider
- C. Apply a cold compress over the IV site
- D. Increase the IV flow rate to prevent dehydration
Correct Answer: B
Rationale: When a client develops phlebitis at the IV site, the nurse's immediate action should be to discontinue the IV and notify the healthcare provider. Phlebitis is inflammation of the vein, and leaving the IV in place can lead to complications such as infection or thrombosis. Administering an anti-inflammatory medication (choice A) may not address the root cause and delay the necessary intervention. Applying a cold compress (choice C) may provide temporary relief but does not address the need to remove the source of inflammation. Increasing the IV flow rate (choice D) is contraindicated as it can exacerbate the phlebitis by causing more irritation to the vein.
A nurse is teaching a client who is at risk for developing osteoporosis. Which of the following recommendations should the nurse make?
- A. Walk for at least 30 minutes each day
- B. Avoid sunlight exposure
- C. Take vitamin B12 supplements
- D. Increase calcium intake to 1,500 mg per day
Correct Answer: D
Rationale: The correct answer is to increase calcium intake to 1,500 mg per day. Adequate calcium intake is essential for maintaining bone density and reducing the risk of osteoporosis. Walking for at least 30 minutes each day is beneficial for overall health but is not as directly related to osteoporosis prevention as calcium intake. Sunlight exposure is important for vitamin D synthesis, which is necessary for calcium absorption, so avoiding sunlight exposure would not be recommended. Vitamin B12 supplements are not directly related to bone health or osteoporosis prevention, so this would not be the most appropriate recommendation.
What are key signs of a urinary tract infection (UTI) in older adults?
- A. Confusion and increased temperature
- B. Painful urination and frequent urination
- C. Dizziness and headache
- D. Back pain and fever
Correct Answer: A
Rationale: The correct answer is A. In older adults, key signs of a UTI often include confusion and increased temperature. Confusion is a common symptom in the elderly when they have a UTI, and an increase in body temperature can indicate an infection. Choices B, C, and D are incorrect because while painful urination and frequent urination are common UTI symptoms in general, they may not be as prominent in older adults. Dizziness, headache, back pain, and fever can be associated with other conditions but are not typically key signs of a UTI in older adults.
What are the key nursing interventions for a patient with a tracheostomy?
- A. Maintain a patent airway and monitor for infection
- B. Suction airway secretions and provide humidified oxygen
- C. Educate patient on self-care and tracheostomy cleaning
- D. Change tracheostomy ties daily
Correct Answer: A
Rationale: The correct answer is to maintain a patent airway and monitor for infection. These are crucial nursing interventions for patients with tracheostomies to ensure adequate oxygenation and prevent complications. Suctioning airway secretions and providing humidified oxygen can be part of the care plan but are not as essential as maintaining a patent airway. Educating the patient on self-care and tracheostomy cleaning is important for long-term management but is not as immediate as ensuring a patent airway and monitoring for infection. Changing tracheostomy ties daily is a specific task related to tracheostomy care but is not as critical as ensuring the airway is clear and infection-free.
A client is to start taking furosemide and is being taught about dietary modifications by a nurse. Which of the following foods should the nurse recommend to the client?
- A. Cabbage
- B. Bananas
- C. Carrots
- D. Potatoes
Correct Answer: B
Rationale: The correct answer is B: Bananas. Bananas are high in potassium, which helps counter the potassium-depleting effects of furosemide. Furosemide is a loop diuretic that can lead to potassium loss, so including potassium-rich foods like bananas in the diet can help maintain a healthy potassium level. Choices A, C, and D do not specifically address the potassium needs associated with furosemide therapy and are not the most appropriate recommendations in this context.