Nokea
Which intervention should be performed when assessing a client with an arteriovenous fistula (AVF) for hemodialysis?
- A. Check the patency of the fistula
- B. Monitor for bleeding
- C. Administer IV fluids
- D. Apply an airtight dressing
Correct Answer: C
Rationale: Correct Answer: C - Administer IV fluids
Rationale:
1. Assess patient's fluid status and hydration level.
2. IV fluids help maintain adequate hydration during hemodialysis.
3. Prevents hypotension and ensures stable blood pressure during the procedure.
4. Improves overall hemodialysis efficiency and patient safety.
Summary:
A: Checking patency is important, but not the primary intervention for hemodialysis.
B: Monitoring for bleeding is crucial but not specific to AVF assessment.
D: Applying an airtight dressing is not necessary for AVF assessment.
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What is the best way to assess a client's nutritional status?
- A. Obtain a dietary history
- B. Monitor serum albumin levels
- C. Monitor the client's weight
- D. Provide a meal plan
Correct Answer: B
Rationale: The correct answer is B: Monitoring serum albumin levels. This is because serum albumin is a protein synthesized by the liver that reflects long-term protein intake and overall nutritional status. Low levels indicate malnutrition or inflammation. Obtaining a dietary history (choice A) is important but may not always reflect the actual nutritional status. Monitoring weight (choice C) is helpful but may not provide a comprehensive view of the client's nutritional status. Providing a meal plan (choice D) is a proactive approach but does not directly assess the client's current nutritional status.
What is the priority nursing action for a client with a suspected stroke?
- A. Administer oxygen
- B. Administer aspirin
- C. Administer thrombolytics
- D. Place the client in a supine position
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygenation is the priority in stroke management to ensure adequate oxygen supply to the brain. Oxygen therapy can help reduce hypoxia, which is crucial in the acute phase of a stroke. Administering aspirin (B) is important but comes after ensuring oxygenation. Administering thrombolytics (C) requires proper assessment and diagnostic confirmation, not an immediate priority. Placing the client in a supine position (D) may worsen stroke symptoms if there is compromised blood flow, so it is not recommended as the initial action.
What should be the nurse's first action for a client with a suspected myocardial infarction (MI)?
- A. Administer nitroglycerin
- B. Monitor cardiac rhythm
- C. Assess the ECG
- D. Assist with positioning
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. This is the nurse's first action for a client with a suspected MI because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can help reduce chest pain and prevent further damage to the heart muscle. Administering nitroglycerin promptly is crucial in managing an MI. Monitoring cardiac rhythm (B) and assessing the ECG (C) are important steps, but administering nitroglycerin takes precedence in addressing the client's immediate symptoms. Assisting with positioning (D) is not as urgent or directly related to managing an MI compared to administering nitroglycerin.
A nurse is assessing a patient who has a history of deep vein thrombosis (DVT). Which of the following findings would be most concerning?
- A. Pain and swelling in the leg.
- B. Redness and warmth around the affected area.
- C. Shortness of breath and chest pain.
- D. Pale skin and decreased pulse in the affected leg.
Correct Answer: C
Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function.
A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism.
B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism.
D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.
Which is an inappropriate item in planning care for a severely neutropenic client?
- A. Transfuse neutrophils
- B. Exclude raw vegetables
- C. Avoid rectal suppositories
- D. Prohibit vases of fresh flowers
Correct Answer: A
Rationale: The correct answer is A: Transfuse neutrophils. Neutrophil transfusion is not a standard treatment for neutropenia as neutrophils do not survive well outside the body. For the other choices: B: Excluding raw vegetables is correct to prevent infection. C: Avoiding rectal suppositories is correct to prevent mucosal injury. D: Prohibiting vases of fresh flowers is correct to prevent exposure to fungal spores. So, transfusing neutrophils is inappropriate as it is not a standard treatment for neutropenia.