Nokea
When should nurses view rehabilitation as a process?
- A. Occurs in the last stage of the patient’s hospitalization
- B. Encompasses all nursing practice goals and activities
- C. Occurs primarily in a specialized unit of the hospital
- D. May not be achieved for all patients
Correct Answer: B
Rationale: Rehabilitation is an integral part of nursing practice that spans all stages of care, focusing on restoring function and independence.
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A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?
- A. Weight gain of 1 kg since the last dialysis session
- B. Blood pressure of 150/90 mm Hg
- C. Potassium level of 6.5 mEq/L
- D. Hemoglobin level of 10 g/dL
Correct Answer: C
Rationale: The correct answer is C: Potassium level of 6.5 mEq/L. High potassium levels in ESRD patients can lead to life-threatening cardiac arrhythmias. Immediate action is needed to prevent complications. A: Weight gain may indicate fluid retention, but it's not an immediate concern. B: Blood pressure is elevated but not an urgent issue. D: Hemoglobin level of 10 g/dL is within the acceptable range for ESRD patients and does not require immediate action.
A client with cirrhosis is experiencing ascites. Which dietary instruction should the nurse provide?
- A. Increase protein intake.
- B. Limit fluid intake to 1500 mL/day.
- C. Consume a low-sodium diet.
- D. Take a daily multivitamin.
Correct Answer: C
Rationale: The correct answer is C: Consume a low-sodium diet. Ascites in cirrhosis is often due to fluid retention caused by impaired liver function. A low-sodium diet helps to reduce fluid buildup in the body, alleviating ascites. Increasing protein intake (A) may worsen ascites by increasing fluid retention. Limiting fluid intake (B) can lead to dehydration, exacerbating the condition. Taking a daily multivitamin (D) may be beneficial for overall health but does not directly address ascites.
A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid exposure to sunlight while taking this medication.
- C. Report any numbness or tingling in extremities.
- D. Have liver function tests done regularly.
Correct Answer: D
Rationale: Step 1: Isoniazid (INH) can cause liver toxicity.
Step 2: Regular liver function tests help monitor for liver damage.
Step 3: Monitoring liver function is crucial to prevent serious complications.
Step 4: Other choices are not directly related to INH's side effects.
Summary: Choice D is correct as it directly addresses a potential serious side effect of INH. Choices A, B, and C are not directly relevant to the medication's side effects.
A client with a history of gastrointestinal bleeding is taking warfarin (Coumadin). Which instruction should the nurse include in the teaching plan?
- A. Avoid eating foods high in vitamin K.
- B. Take aspirin for pain relief.
- C. Report any signs of bruising or bleeding to your healthcare provider.
- D. Limit fluid intake to 2 liters per day.
Correct Answer: C
Rationale: The correct answer is C: Report any signs of bruising or bleeding to your healthcare provider. This instruction is crucial because warfarin can increase the risk of bleeding, especially in clients with a history of gastrointestinal bleeding. Reporting any signs of bruising or bleeding promptly allows for timely intervention to prevent serious complications.
A: Avoiding foods high in vitamin K is not necessary, as consistent intake of vitamin K-containing foods can help maintain stable anticoagulant levels.
B: Taking aspirin along with warfarin can increase the risk of bleeding and should be avoided.
D: Limiting fluid intake is not directly related to the management of warfarin therapy or gastrointestinal bleeding.
What is one reason that might apply to a client’s rationale for using alternative therapy?
- A. Desire to become more active in decision-making and self-care.
- B. Chronic incurable back condition.
- C. Difficulty meeting the rising costs of healthcare.
- D. Client does not share traditional American health beliefs and practices.
Correct Answer: A
Rationale: Clients often seek alternative therapies to take a more active role in their healthcare decisions and self-management.