Nursing Elites

1. 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.

2. For a client with peripheral vascular disease (PVD) of the lower extremities who is trying to manage their condition well, which routine should the nurse evaluate as appropriate?

• A. Resting with the legs elevated above the level of the heart.
• B. Walking slowly but steadily for 30 minutes twice a day.
• C. Minimizing activity.
• D. Wearing antiembolism stockings at all times when out of bed.

Correct answer: B

Rationale: The correct answer is B. Walking slowly but steadily for 30 minutes twice a day is appropriate for clients with PVD as it helps stimulate collateral circulation and improve blood flow. Choice A is incorrect because while elevating the legs can help with symptoms temporarily, it is not as effective as walking for improving circulation. Choice C, minimizing activity, is not recommended as it can lead to further deconditioning and worsen symptoms. Choice D, wearing antiembolism stockings, is not specifically indicated for PVD and may not address the underlying circulation issues.

3. The nurse is caring for a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings should be reported immediately to the physician?

• A. Clear dialysate outflow.
• B. Increased blood pressure.
• C. Cloudy dialysate outflow.
• D. Decreased urine output.

Correct answer: C

Rationale: Cloudy dialysate outflow should be reported immediately to the physician. It is indicative of peritonitis, a severe infection of the peritoneal cavity and a serious complication of peritoneal dialysis. Prompt medical attention is crucial to prevent further complications or systemic infection. Clear dialysate outflow (Choice A) is a normal finding in peritoneal dialysis. Increased blood pressure (Choice B) and decreased urine output (Choice D) are common in clients with chronic renal failure and may not require immediate reporting unless they are significantly abnormal or accompanied by other concerning symptoms.

4. A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing preprocedure instructions, should tell the client to:

• A. Eat a regular supper and breakfast
• B. Remove all metal and jewelry before the test
• C. Expect diarrhea for a few days after the procedure
• D. Take all oral medications as scheduled with milk on the day of the test

Correct answer: B

Rationale: The correct answer is B: 'Remove all metal and jewelry before the test.' Before a barium swallow procedure, the client should fast for 8 to 12 hours to ensure the stomach and intestines are empty for optimal visualization. Removing all metal and jewelry is essential to prevent any interference with x-ray imaging. Choice A is incorrect because the client should fast, not eat supper and breakfast, before the test. Choice C is incorrect as diarrhea is not an expected outcome of a barium swallow. Choice D is incorrect as the client should not take any oral medications with milk on the day of the test to ensure accurate test results.

5. The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

• A. Protect the skin of the radiation portal site from sunlight exposure
• B. Apply moisturizing lotions daily to the radiation portal site
• C. Avoid washing the skin inside the radiation portal site
• D. Remove the ink marks of the portal after each radiation treatment

Correct answer: A

Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.

Similar Questions