Nokea
What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.
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A hospice client's family asks how they will know when death is imminent. The nurse should explain that signs include:
- A. Increased energy and mobility.
- B. Cheyne-Stokes respirations.
- C. Improved blood pressure.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Cheyne-Stokes respirations, characterized by alternating periods of apnea and deep breathing, are a common sign of imminent death.
For which of the following preoperative clients should the nurse assess the glucose level? Select all that apply.
- A. A client with diabetes mellitus controlled by diet.
- B. A client with a high stress response to surgery.
- C. A client receiving corticosteroids for the past 3 months.
- D. A client with a family history of diabetes receiving dextrose 5% in lactated Ringer's solution (D5LR) I.V. fluids.
- E. A client who consumes a high carbohydrate diet.
Correct Answer: A,B,C,D
Rationale: Clients at risk for hyperglycemia include those with diabetes (A), high stress response (B, due to cortisol release), recent corticosteroid use (C, which raises glucose), and those receiving dextrose-containing IV fluids with a family history of diabetes (D). A high carbohydrate diet alone (E) is less likely to warrant immediate glucose monitoring.
The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis?
- A. Avoid the use of caffeinated beverages.
- B. Perform postural drainage every day.
- C. Take hot showers twice daily.
- D. Report a temperature of 102°F (38.9°C) or higher.
Correct Answer: C,D
Rationale: Hot showers help moisten nasal passages and promote sinus drainage, relieving symptoms of chronic sinusitis. Reporting a high fever is critical as it may indicate a worsening infection requiring medical attention. Caffeine restriction is not typically necessary. Postural drainage is more relevant for lung conditions like bronchiectasis.
Which position is best for a client with a hemorrhagic stroke?
- A. Flat supine.
- B. Head elevated 30 degrees.
- C. Prone position.
- D. Trendelenburg position.
Correct Answer: B
Rationale: Head elevation at 30 degrees reduces intracranial pressure while maintaining cerebral perfusion in hemorrhagic stroke.
The nurse is preparing a client for a total hip replacement. Which preoperative teaching should be included to prevent postoperative complications?
- A. Avoid crossing legs after surgery.
- B. Practice using a walker before surgery.
- C. Limit fluid intake the day before surgery.
- D. Perform arm exercises to strengthen muscles.
Correct Answer: A
Rationale: Avoiding leg crossing prevents hip dislocation, a common complication after total hip replacement. This teaching is critical for postoperative safety and recovery.