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Question 1 of 5

When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority?

Correct Answer: C

Rationale: Ask for a log of urinary output. Monitoring urine output is the best indicator of renal function in pyelonephritis.

Question 2 of 5

The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?

Correct Answer: B

Rationale: Restricting potassium isn't indicated for Ménière's disease; a low-sodium diet is typically recommended to reduce fluid retention. Smoking cessation, lying down during attacks, and limiting caffeine/alcohol are appropriate.

Question 3 of 5

The nurse is caring for a client with Kawasaki disease. Which of the following actions would be a priority for the nurse to take?

Correct Answer: B

Rationale: A quiet, restful environment reduces irritability and stress in Kawasaki disease, promoting recovery. Monitoring heart sounds/urine output is secondary, as cardiac complications are less immediate. Cool compresses and soft foods are less critical.

Question 4 of 5

The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding would the nurse expect?

Correct Answer: D

Rationale: Characteristic limp. Developmental dysplasia produces a characteristic limp in children who are walking, indicating hip joint instability.

Question 5 of 5

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain and is scheduled for paracentesis. Which of the following nursing actions should be implemented prior to the procedure? Select all that apply.

Correct Answer: A,D,E

Rationale: Informed consent ensures understanding, emptying the bladder prevents injury during needle insertion, and baseline vital signs/weight monitor fluid shifts. Reverse Trendelenburg is inappropriate; upright positioning is typical. NPO status isn't required for paracentesis.

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