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Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
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A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Encourage the client to cough and deep breathe.
- C. Auscultate the lungs to detect abnormal breath sounds.
- D. Contact the physician.
Correct Answer: D
Rationale: Sudden dyspnea, tachypnea, and chest discomfort suggest a pulmonary embolism, a medical emergency. Contacting the physician first ensures rapid intervention. Elevating the bed, encouraging coughing, or auscultating lungs delays critical treatment.
Which of the following is the most common initial manifestation of acute renal failure?
- A. Dysuria.
- B. Anuria.
- C. Hematuria.
- D. Oliguria.
Correct Answer: D
Rationale: Oliguria, reduced urine output, is the most common initial sign of acute renal failure due to impaired kidney filtration.
What is the nurse's best response to a client with Parkinson's experiencing dyskinesia?
- A. Increase medication dose.
- B. Teach relaxation techniques.
- C. Restrict all activity.
- D. Ignore the symptoms.
Correct Answer: B
Rationale: Teaching relaxation techniques can help manage dyskinesia, a side effect of Parkinson's medications.
Which of the following is a priority nursing diagnosis for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza?
- A. Imbalanced nutrition: Less than body requirements.
- B. Ineffective health maintenance related to ineffective coping skills.
- C. Acute pain.
- D. Activity intolerance.
Correct Answer: A
Rationale: Nausea and vomiting from illness can lead to inadequate food intake, causing imbalanced nutrition, a priority due to the risk of hypoglycemia or ketoacidosis.
Which of the following is contraindicated for a client diagnosed with disseminated intravascular coagulation (DIC)?
- A. Treating the underlying cause.
- B. Administering heparin.
- C. Administering warfarin sodium (Coumadin).
- D. Replacing depleted blood products.
Correct Answer: C
Rationale: Warfarin is contraindicated in DIC because it further inhibits clotting factors, worsening bleeding. Treating the underlying cause, administering heparin (to stop clotting), and replacing blood products are standard treatments to manage DIC.