Nokea
A client is currently hospitalized with renal failure and has 3+ pitting edema of the lower extremities.
Which of the following nursing observations would indicate a therapeutic response to therapy for the edema?
- A. Serum potassium 4.0 mEq/L.
- B. Plasma glucose 140 mg/dL.
- C. Increased specific gravity of the urine.
- D. Weight loss of 5 lb over last two days.
Correct Answer: D
Rationale: Strategy: Determine how each answer choice relates to edema. (1) no relation to edema (2) no relation to edema (3) urine specific gravity may be decreased as client begins to lose some edema fluid (4) correct-edema is a result of sodium and fluid retention; weight loss should occur if therapy is effective
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The nurse is caring for a client with a history of seizures who is receiving phenytoin (Dilantin) 100 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I brush my teeth twice a day.
- B. I take my medication with milk.
- C. I have a rash on my arms.
- D. I feel drowsy in the morning.
Correct Answer: C
Rationale: A rash may indicate a hypersensitivity reaction to phenytoin, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate evaluation. Options A, B, and D are less concerning: brushing teeth is routine, milk does not affect absorption, and drowsiness is a common side effect.
The nurse is planning discharge for a client who suffered a mild myocardial infarction (MI) and smokes one pack of cigarettes per day.
Which of the following recommendations by the nurse would be BEST?
- A. Participation in a program such as 'Nicotine Avoidance.'
- B. Avoidance of aerobic physical activity.
- C. Instillation of a humidifier in the home heating system.
- D. Strict adherence to a low-calorie, low-sodium, high-lipid diet.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-smoking is definitely a modifiable risk factor, self-help program can significantly aid in quitting (2) well-planned aerobic physical activity program is a must (3) humidification does not modify the risk factors (4) low-calorie is appropriate, needs a low-fat, not a high-fat, diet
A victim of domestic violence states to the nurse, 'If only I could change and be how my companion wants me to be, I know things would be different.' Which would be the best response by the nurse?
- A. The violence is temporarily caused by unusual circumstances, don't stop hoping for a change.
- B. Perhaps, if you understood the need to abuse, you could stop the violence.
- C. No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?
- D. Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do.
Correct Answer: D
Rationale: Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do. This clarifies that the abuser is responsible for the violence.
The nurse is caring for a client with a history of chronic kidney disease who is receiving epoetin alfa (Epogen). Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Hemoglobin 14 g/dL.
- B. Potassium 4.5 mEq/L.
- C. Creatinine 3.0 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: A hemoglobin of 14 g/dL is too high for epoetin alfa therapy, increasing the risk of hypertension and thrombosis, requiring dose adjustment. Options B, C, and D are expected: potassium 4.5 mEq/L and calcium 9.0 mg/dL are normal, and creatinine 3.0 mg/dL is consistent with chronic kidney disease.
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix) 40 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.2 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.0 mg/dL.
- D. Glucose 100 mg/dL.
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia, and a potassium level of 3.2 mEq/L is low, increasing the risk of arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.0 mg/dL, and glucose 100 mg/dL do not require immediate action.