Nokea
Which nursing intervention is most helpful in assisting the client undergoing hemodialysis to cope with the client and the patient to the patient?
- A. Giving the client literature to read about renal failure
- B. Advising the client's spouse to cook the client's favorite dishes
- C. Keeping the client informed of the latest research findings
- D. Exploring with the client how this disorder has affected life
Correct Answer: D
Rationale: Exploring the impact of the disorder on the client's life fosters emotional coping and supports psychosocial adjustment.
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Which statement indicates discharge teaching has been effective for the client who is postoperative TURP?
- A. I will call the surgeon if I experience any difficulty urinating.'
- B. I will take my Proscar daily, the same as before my surgery.'
- C. I will continue restricting my oral fluid intake.'
- D. I will take my pain medication routinely even if I do not hurt.'
Correct Answer: A
Rationale: Difficulty urinating post-TURP may indicate obstruction or complications, requiring prompt reporting. Proscar is typically discontinued post-TURP, fluid restriction is unnecessary, and routine pain meds are not advised.
Before peritoneal dialysis begins, the nurse correctly informs the client that the procedure involves the movement of urea and creatinine through the peritoneum by which means?
- A. Osmosis
- B. Diffusion
- C. Filtration
- D. Gravity
Correct Answer: B
Rationale: Diffusion is the primary mechanism by which urea and creatinine move across the peritoneal membrane during dialysis.
The nurse is inserting an indwelling catheter into a female client. Which interventions should be implemented? Rank in the order of performance.
- A. Explain the procedure to the client.
- B. Set up the sterile field.
- C. Inflate the catheter bulb.
- D. Place absorbent pads under the client.
- E. Clean the perineum from clean to dirty with Betadine.
Correct Answer: A,D,B,E,C
Rationale: Correct order: 1) Explain the procedure to gain consent and reduce anxiety; 2) Place absorbent pads to maintain a clean field; 3) Set up the sterile field to prepare equipment; 4) Clean the perineum (front to back, not clean to dirty, assuming document error) to reduce infection risk; 5) Inflate the catheter bulb after insertion to secure it.
The nurse caring for a client diagnosed with CKD writes a client problem of 'noncompliance with dietary restrictions.' Which intervention should be included in the plan of care?
- A. Teach the client the proper diet to eat while undergoing dialysis.
- B. Refer the client and significant other to the dietitian.
- C. Explain the importance of eating the proper foods.
- D. Determine the reason for the client not adhering to the diet.
Correct Answer: D
Rationale: Determining the reason for noncompliance (e.g., lack of understanding, financial barriers) is the first step to tailor interventions effectively. Teaching, referrals, or explaining importance are secondary until the root cause is identified.
The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first?
- A. The client in normal sinus rhythm with a peaked T wave.
- B. The client diagnosed with atrial fibrillation with a rate of 100.
- C. The client diagnosed with a myocardial infarction who has occasional PVCs.
- D. The client with a first-degree atrioventricular block and a rate of 92.
Correct Answer: A
Rationale: Peaked T waves indicate hyperkalemia, which can lead to life-threatening arrhythmias, requiring immediate assessment. Atrial fibrillation, PVCs, and first-degree AV block are less urgent unless unstable.