the nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease ckd which assessment finding should the nurse report to
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Nursing Elites

HESI LPN

HESI CAT Exam

1. The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider?

Correct answer: A

Rationale: Cloudy dialysate fluid can indicate peritonitis, a serious complication of peritoneal dialysis. Peritonitis is an urgent condition that requires immediate evaluation and treatment. Reporting this finding promptly is crucial to prevent further complications. Choices B, C, and D are not indicative of peritonitis and do not require immediate reporting to the healthcare provider. Complaining of slight shortness of breath, having a greater return volume, and experiencing abdominal fullness and cramping are common occurrences during peritoneal dialysis and do not necessarily indicate an emergent issue.

2. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home”. What response is best for the nurse to provide?

Correct answer: A

Rationale: The correct response is A: 'Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely.' Heparin is an anticoagulant that prevents further clot formation, but it does not quickly dissolve existing clots. It is crucial for the nurse to educate the client about the purpose of heparin and the necessity for close monitoring of bleeding risks. Choice B is incorrect as it does not address the misunderstanding about heparin's mechanism of action. Choice C is incorrect as home administration of IV heparin therapy requires careful consideration and should not be suggested without a thorough assessment. Choice D is incorrect as it does not address the client's misconception about heparin's role in dissolving clots and instead focuses on the client's desire to leave the hospital.

3. A 13-year-old girl, diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

Correct answer: B

Rationale: The correct answer is B. Incorrect insulin administration is a common cause of diabetic ketoacidosis. Administering too much insulin can lead to uncontrolled hyperglycemia, where the body starts breaking down fat for energy, resulting in the production of ketones. Choices A, C, and D are less likely to directly cause diabetic ketoacidosis. Eating an extra peanut butter sandwich, skipping lunch, or having a cold and ear infection would not directly lead to the metabolic derangements seen in diabetic ketoacidosis.

4. The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

Correct answer: A

Rationale: Encouraging the parents to allow the child to continue attending swimming lessons with supervision is the most appropriate response. Swimming can be beneficial for the child, providing both exercise and enjoyment. Supervision can help manage any risks associated with swimming. Choice B is incorrect because the child's preference for swimming should be respected, and swimming can still offer socialization opportunities. Choice C is incorrect as it undermines the child's capability to understand the situation. Choice D is less appropriate as it does not address the child's interest in swimming and may limit beneficial physical activity.

5. The public health nurse received funding to initiate a primary prevention program in the community. Which program best fits the nurse’s proposal?

Correct answer: C

Rationale: The correct answer is C: Vitamin supplements for high-risk pregnant women. This option aligns with primary prevention by preventing deficiencies before they occur, which is a key aspect of primary prevention. Providing vitamin supplements to high-risk pregnant women can help prevent birth defects and complications. Choices A, B, and D do not align with primary prevention strategies. Case management and screening for clients with HIV (Choice A) is more of a secondary prevention strategy aimed at early detection and management. A regional relocation center for earthquake victims (Choice B) is focused on addressing the aftermath of a disaster rather than preventing it. Lead screening for children in low-income housing (Choice D) is more about early detection and intervention rather than primary prevention.

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