Nokea
When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority?
- A. Follow-up on lab values before the visit
- B. Observe client findings for the effectiveness of antibiotics
- C. Ask for a log of urinary output
- D. Ask for the log of the oral intake
Correct Answer: C
Rationale: Ask for a log of urinary output. Monitoring urine output is the best indicator of renal function in pyelonephritis.
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The nurse is caring for a client with partial hearing loss. Which of the following actions will promote effective communication? Select all that apply.
- A. Dim lights to prevent overstimulation
- B. Directly face the client when speaking
- C. Ensure hearing aids are properly applied
- D. Provide written information to supplement conversation
- E. Raise voice to speak loudly to the client
Correct Answer: B,C,D
Rationale: Facing the client aids lip-reading, properly applied hearing aids optimize hearing, and written information reinforces verbal communication. Dimming lights may hinder lip-reading, and shouting distorts speech.
The nurse is reinforcing discharge teaching to several clients with new prescriptions. Which instructions by the nurse about medication administration are correct? Select all that apply.
- A. Avoid salt substitutes when taking valsartan for hypertension
- B. Take levofloxacin with an aluminum antacid to avoid gastric irritation
- C. Take sucralfate (for a gastric ulcer) after meals to minimize gastric irritation
- D. When taking ethambutol, notify the health care provider (HCP) for changes in vision
- E. When taking rifampin, notify the HCP if the urine turns red-orange in color
Correct Answer: A,D
Rationale: Salt substitutes (potassium-based) can cause hyperkalemia with valsartan. Ethambutol can cause optic neuritis, requiring vision change reports. Levofloxacin with antacids reduces absorption. Sucralfate is taken before meals to coat the stomach. Rifampin's red-orange urine is normal, not reportable.
The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?
- A. The injury is expected to heal quickly because of thin periosteum.'
- B. In some instances the result is a retarded bone growth.'
- C. Bone growth is stimulated in the affected leg.'
- D. This type of injury shows more rapid union than that of younger children.'
Correct Answer: B
Rationale: An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded bone growth. The leg often will be different in length than the uninjured leg.
Which nursing diagnosis is least likely to apply to the client admitted with a diagnosis of borderline personality disorder?
- A. Risk for self-injury
- B. Identity disturbance
- C. Self-esteem disturbance
- D. Sensory-perceptual alteration
Correct Answer: D
Rationale: Borderline personality disorder is characterized by self-injury, identity issues, and low self-esteem, making A, B, and C relevant. Sensory-perceptual alteration is more associated with psychotic disorders, so D is least likely.
A home care client is scheduled for dialysis. He asks the nurse if he should take his antihypertensive medication before going for dialysis. How should the nurse respond?
- A. He should take all regularly scheduled medications.
- B. Antihypertensives should not be taken before dialysis because the blood pressure drops during dialysis.
- C. He should check with the physician because it varies from person to person.
- D. He should take it with him and take it if his blood pressure rises during the treatment.
Correct Answer: B
Rationale: Antihypertensives are often held before dialysis to prevent hypotension, as dialysis can lower blood pressure. Routine administration, physician checks, or conditional dosing are less appropriate.