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. Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form?

Correct answer: D

Rationale: The correct answer is D because an illiterate client may require additional support to ensure they fully comprehend the information provided in the informed consent process. It is crucial to confirm that the client truly understands the nature of the procedure, its risks, and benefits. While it is important to assess pain control (choice A), a client's previous medication administration does not directly impact their ability to understand the consent process. Choice B, a 15-year-old primigravida who has been self-supporting, may legally provide informed consent depending on the jurisdiction and circumstances, so this situation may not require further exploration. Choice C, explaining a procedure by a different specialist, does not necessarily require additional exploration before witnessing the client's consent.

3. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

Correct answer: B

Rationale: The correct instruction to include in the discharge teaching for a client following cataract extraction is to 'Avoid straining during stool passage, bending, or lifting heavy objects.' This is crucial to prevent increased intraocular pressure after surgery, which can be harmful. Reading with direct lighting can strain the eyes but is not the primary concern post-cataract surgery. Irrigating the conjunctiva before applying antibiotic ointment is not a standard practice and may not be necessary. While limiting sunlight exposure is important for eye protection, it is secondary to avoiding activities that can increase intraocular pressure.

4. A man calls the hospital and asks to talk with the nurse about his girlfriend who was extremely intoxicated on admission and is receiving services for detoxification. He knows that she is in the facility and asks the nurse about her condition. What is the nurse's best response?

Correct answer: C

Rationale: The nurse must adhere to confidentiality rules and cannot confirm the presence or condition of the client. Choice A is incorrect because disclosing the client's condition breaches confidentiality. Choice B is wrong as it reveals the client's room number, which is also a breach of confidentiality. Choice D is not the best response as it involves sharing information about the client without verifying the caller's identity or relationship to the client.

5. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm?

Correct answer: A

Rationale: The correct intervention the nurse should implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm is to assess the IV site frequently for signs of extravasation. Vesicants are agents that can cause tissue damage if they leak into the surrounding tissues. Monitoring for signs of extravasation such as swelling, pain, or redness is crucial to prevent tissue damage and ensure prompt intervention if extravasation occurs. Choices B, C, and D are incorrect because monitoring capillary refill, applying a topical anesthetic for burning, and explaining temporary burning do not directly address the risk of extravasation associated with vesicant chemotherapeutic agents.

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