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What are the potential complications of a patient receiving hemodialysis?
- A. Infection and hypotension
- B. Pulmonary embolism and fluid overload
- C. Blood clot formation and electrolyte imbalance
- D. Low blood pressure and nausea
Correct Answer: A
Rationale: Corrected Question: What are the potential complications of a patient receiving hemodialysis?
Rationale: Infection and hypotension are common complications in patients undergoing hemodialysis. Pulmonary embolism and fluid overload (Choice B) are less common complications associated with hemodialysis. Blood clot formation and electrolyte imbalance (Choice C) are also potential complications but are not as common as infection and hypotension. Low blood pressure and nausea (Choice D) can occur but are not as prevalent as infection and hypotension.
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A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include?
- A. Give a bedtime snack
- B. Encourage a short nap in the afternoon
- C. Encourage exercise right before bed
- D. Establish a regular exercise routine 2 hours or more before bedtime
Correct Answer: D
Rationale: The correct answer is D. Establishing a regular exercise routine at least 2 hours before bedtime promotes better sleep in older adults. Giving a bedtime snack (choice A) may disrupt sleep due to digestion, encouraging a short nap in the afternoon (choice B) can interfere with nighttime sleep, and encouraging exercise right before bed (choice C) can increase alertness and make it harder to fall asleep.
A healthcare professional is planning care for a client who has a prescription for mechanical restraints. Which of the following interventions should the healthcare professional include in the plan?
- A. Document the client's status every 60 minutes.
- B. Provide a staff member to stay with the client continuously.
- C. Measure vital signs every 4 hours.
- D. Obtain a prescription for the restraints every 8 hours.
Correct Answer: B
Rationale: When a client has a prescription for mechanical restraints, it is essential to provide continuous monitoring for their safety and to observe any behavioral changes. Having a staff member stay with the client continuously allows for immediate intervention if needed. Documenting the client's status every 60 minutes (Choice A) may not provide real-time monitoring, which is crucial in this situation. While measuring vital signs every 4 hours (Choice C) is important, continuous observation takes precedence in this scenario. Obtaining a prescription for the restraints every 8 hours (Choice D) is not a necessary intervention once the initial prescription is in place.
A nurse is caring for a client who has hypertension and is receiving enalapril. Which of the following findings should the nurse report to the provider?
- A. Increased heart rate
- B. Persistent cough
- C. Constipation
- D. Sweating
Correct Answer: B
Rationale: The correct answer is B: Persistent cough. Enalapril is an ACE inhibitor that can cause a persistent cough as a common side effect. This symptom should be reported to the healthcare provider to evaluate if a medication adjustment is needed. Choices A, C, and D are not typically associated with enalapril use and are less likely to be directly related to the medication. Increased heart rate, constipation, and sweating are not commonly linked to enalapril, so they are not the priority findings to report in this case.
A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin A1c of 6%
- B. Fasting blood glucose of 90 mg/dL
- C. Blood glucose of 200 mg/dL
- D. Blood glucose of 100 mg/dL
Correct Answer: C
Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.
A nurse is caring for a client post-op with a chest tube. What should the nurse check for regularly?
- A. Ensure the chest tube is periodically clamped
- B. Check for air leaks in the tubing
- C. Keep the client in a prone position for chest drainage
- D. Administer diuretics to prevent fluid buildup
Correct Answer: B
Rationale: The correct answer is to check for air leaks in the tubing. Air leaks can compromise the function of the chest tube, leading to inadequate drainage and potentially causing complications for the client. Clamping the chest tube periodically is incorrect as it could lead to a buildup of fluid or air in the pleural space. Keeping the client in a prone position is not necessary for chest drainage, as the positioning may vary depending on the specific situation. Administering diuretics may not be directly related to monitoring the chest tube for proper function and is not a routine intervention for chest tube management post-op.