Nokea
Which of the following is a common cause of acute kidney injury?
- A. Hypertension
- B. Dehydration
- C. Infection
- D. Hypotension
Correct Answer: C
Rationale: Infection is a common cause of acute kidney injury because when the body fights an infection, it activates the immune response, leading to inflammation. This inflammatory response can affect the kidneys and impair their function. While hypertension (choice A) is a risk factor for chronic kidney disease, it is not a direct cause of acute kidney injury. Dehydration (choice B) can lead to prerenal acute kidney injury due to decreased blood flow to the kidneys, but infection is a more common cause of acute kidney injury. Hypotension (choice D) can contribute to prerenal acute kidney injury, but it is not a direct cause like infection.
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The client has been receiving peritoneal dialysis. The nurse should assess the client for which of the following complications that is most likely to occur?
- A. Electrolyte imbalance
- B. Peritonitis
- C. Infection
- D. Hyperglycemia
Correct Answer: B
Rationale: Peritonitis is the most likely complication to occur in clients receiving peritoneal dialysis due to the risk of infection. Peritonitis is a serious inflammation of the peritoneum lining the abdominal cavity, commonly caused by infection. While electrolyte imbalance and hyperglycemia are possible complications in some cases, peritonitis poses a more immediate and severe threat to the client's health. Infection is a general term that can encompass peritonitis but is not as specific as directly identifying peritonitis as the primary concern in this scenario.
The client with peripheral artery disease has been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following?
- A. I should not be surprised if I bruise more easily or if my gums bleed a little when brushing my teeth.
- B. It is important to take this medicine with food to enhance its effectiveness and minimize stomach upset.
- C. I should stop taking Plavix if it makes me feel weak and dizzy.
- D. The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming.
Correct Answer: C
Rationale: The correct answer is C. Weakness, dizziness, and headache are common adverse effects of Plavix and should be reported. It is essential to consult a physician before stopping Plavix as it plays a crucial role in preventing platelets from sticking together and forming clots. Choices A, B, and D are incorrect. Choice A is a common side effect of Plavix and does not indicate a need for further teaching. Choice B is incorrect because taking Plavix with or without food can affect its absorption and effectiveness. Choice D correctly explains the purpose of prescribing Plavix to prevent clot formation.
The client with chronic renal failure is on a fluid restriction. Which of the following statements by the client indicates that the teaching has been effective?
- A. I will limit my fluid intake to prevent fluid overload.
- B. I can drink as much fluid as I want as long as I take my medication.
- C. I will skip dialysis sessions if I feel tired.
- D. I will limit my fluid intake to 1 liter per day.
Correct Answer: A
Rationale: Choice A is the correct answer because it demonstrates the client's understanding of the need to limit fluid intake to prevent fluid overload, which is crucial in managing chronic renal failure. Adequate fluid restriction is essential to prevent complications such as fluid overload and electrolyte imbalances. Choice B is incorrect as it promotes excessive fluid intake, which can worsen the client's condition by putting additional stress on the kidneys. Choice C is incorrect as skipping dialysis sessions can lead to a buildup of toxins in the body, worsening renal failure and potentially leading to life-threatening complications. Choice D is incorrect because limiting fluid intake to a specific volume may not be appropriate for all clients and can vary depending on individual needs, medical condition, and healthcare provider recommendations.
The client with deep vein thrombosis (DVT) in the left lower leg is receiving heparin therapy. Which of the following assessments is the most important for the nurse to perform?
- A. Measure the circumference of the left leg.
- B. Assess for signs of bleeding, such as bruising or hematuria.
- C. Monitor the client's vital signs.
- D. Monitor the client's respiratory status.
Correct Answer: B
Rationale: The most important assessment for a client with DVT on heparin therapy is to monitor for signs of bleeding, such as bruising or hematuria. Heparin is an anticoagulant medication that can increase the risk of bleeding. Assessing for bleeding is crucial to prevent complications like hemorrhage. Measuring the circumference of the leg may be relevant for assessing for edema but is not as critical as monitoring for bleeding. Monitoring vital signs and respiratory status are important aspects of care but are not the priority when the client is on heparin therapy for DVT.
A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
- A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
- B. Administer oxygen via nasal cannula.
- C. Offer pain medication for the chest heaviness.
- D. Inform the physician of the chest heaviness.
Correct Answer: A
Rationale: The correct first nursing action when a client reports chest heaviness post-hip surgery is to gather more information through assessment. Inquiring about the onset, duration, severity, and precipitating factors of the heaviness is crucial to determine the cause. This approach helps the nurse to gather essential data to make an informed decision regarding the client's care. Administering oxygen (Choice B) may be indicated based on assessment findings, but it is crucial to assess first. Offering pain medication (Choice C) without further assessment is premature and may mask symptoms. Informing the physician (Choice D) should be done after a thorough assessment to provide comprehensive information for appropriate medical decision-making.