Nokea
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.
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The nurse should teach the client with Addison's disease that the adverse effect of bronze-colored skin is thought to be caused by which of the following?
- A. Hypersensitivity to sun exposure.
- B. Increased serum bilirubin level.
- C. Adverse effects of the glucocorticoid therapy.
- D. Increased secretion of adrenocorticotropic hormone (ACTH).
Correct Answer: D
Rationale: Bronze-colored skin in Addison's disease results from increased ACTH, which stimulates melanin production.
The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube:
- A. For administration of oxygen.
- B. To promote formation of lung scar tissue.
- C. To insert antibiotics into the pleural space.
- D. To remove air and fluid.
Correct Answer: D
Rationale: A chest tube in pneumothorax removes air and fluid from the pleural space, restoring lung expansion. It is not used for oxygen, scar tissue, or antibiotics.
The nurse is reading the results of a tuberculin skin test (see fi gure). The nurse should interpret the results as:
- A. Negative
- B. Needing to be repeated.
- C. Positive.
- D. False.
Correct Answer: C
Rationale: The tuberculin test is positive. The test should be interpreted 2 to 3 days after administering the purifi ed protein derivative (PPD) by measuring the size of the fi rm, raised area (induration). Positive responses indicate that the client may have been exposed to the tuberculosis bacteria. A negative response is indicated by the absence of a fi rm, raised area, or an area that is less than 5 mm in diameter. Since the test is positive, it is not necessary to redo the test. The test is positive, not false.
A client with acute renal failure is prescribed a low-potassium diet. Which food should be avoided?
- A. Bananas.
- B. Rice.
- C. Apples.
- D. Bread.
Correct Answer: A
Rationale: Bananas are high in potassium, unsuitable for a low-potassium diet.
A client has returned to the medical-surgical unit after a cardiac catheterization. Which is the most important initial postprocedure nursing assessment for this client?
- A. Monitor the laboratory values.
- B. Observe neurologic function every 15 minutes.
- C. Observe the puncture site for swelling and bleeding.
- D. Monitor skin warmth and turgor.
Correct Answer: C
Rationale: Observing the puncture site for swelling and bleeding is critical post-catheterization to detect complications like hematoma or hemorrhage.