Nokea
What is a goal of care for a client with acute renal failure?
- A. Maintain urine output of 30 mL/hour.
- B. Keep potassium above 5.5 mEq/L.
- C. Increase protein intake.
- D. Limit ambulation.
Correct Answer: A
Rationale: Maintaining adequate urine output indicates improving renal function.
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Which of the following activities indicates that the client with cancer is adapting well to body image changes?
- A. The client names his brother as the person to call if he is experiencing suicidal ideation.
- B. The client discusses changes in body structure and function.
- C. The client discusses the date of his return to work.
- D. The client serves as a volunteer in a client-to-client visitation program.
Correct Answer: D
Rationale: Volunteering in a client-to-client program indicates positive adaptation to body image changes, as it reflects confidence and engagement with others despite physical changes.
The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate?
- A. Increase calories.
- B. Restrict sodium.
- C. Restrict potassium.
- D. Reduce fat to 10%.
Correct Answer: B
Rationale: Restricting sodium helps manage fluid retention and hypertension in Cushing's disease due to aldosterone excess.
The client asks the nurse, 'Is it really possible to lead a normal life with an ileostomy?' Which action by the nurse would be the most effective to address this question?
- A. Have the client talk with a member of the clergy about these concerns.
- B. Tell the client to worry about those concerns after surgery.
- C. Arrange for a person with an ostomy to visit the client preoperatively.
- D. Notify the surgeon of the client's question.
Correct Answer: C
Rationale: Arranging for a person with an ostomy to visit provides a relatable, firsthand perspective, addressing the client's concerns about normalcy effectively. Clergy, postponing concerns, or notifying the surgeon are less direct or supportive. CN: Psychosocial adaptation; CL: Synthesize
When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following?
- A. Drug-induced hemolytic anemia.
- B. Purpura.
- C. Infectious emboli.
- D. Ecchymosis.
Correct Answer: A
Rationale: Cephalosporins can rarely cause drug-induced hemolytic anemia by triggering an immune response that destroys red blood cells. The nurse should monitor for signs such as jaundice, dark urine, or a drop in hemoglobin. Purpura, infectious emboli, and ecchymosis are not commonly associated with cephalosporin use.
Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which complication?
- A. Gastrointestinal bleeding.
- B. Myocardial infarction.
- C. Emesis.
- D. Rib fracture.
Correct Answer: D
Rationale: Incorrect hand placement during CPR can cause rib fractures, which, while sometimes unavoidable, can be minimized with proper technique, such as placing hands at the center of the chest over the lower half of the sternum.