A client on hemodialysis is complaining of muscle weakness and numbness in his legs. His lab results are: Na 136 mEq/L, K 5.9 mEq/L, Cl 100 mEq/L, ca 8.5 mg/dl. Which electrolyte imbalance is the client suffering from?

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In hemodialysis, potassium levels can be elevated due to impaired renal excretion. High potassium can lead to muscle weakness and numbness. The client's K level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), confirming hyperkalemia. Na, Cl, and Ca levels are within normal limits, ruling out hypernatremia, hypochloremia, and hypocalcemia as the client's primary electrolyte imbalance. Monitoring and managing hyperkalemia are crucial to prevent life-threatening complications like cardiac arrhythmias.

Correct Answer: A

Rationale: The correct answer is A: Vision changes. Tamoxifen can cause serious ocular side effects like retinopathy and corneal changes. These adverse reactions can lead to vision impairment or loss, which is crucial to report immediately to prevent permanent damage. Headache (B), hearing loss (C), and anorexia (D) are not typically associated with tamoxifen use and do not pose immediate threats to the client's health compared to vision changes. It is important for the nurse to prioritize educating the client on recognizing and reporting vision changes promptly to ensure timely intervention and prevent irreversible consequences.

Correct Answer: A

Rationale: Step 1: Regular aerobic exercise helps lower blood pressure by improving heart health and circulation. Step 2: Exercise reduces stress and promotes weight loss, factors that contribute to hypertension control. Step 3: Alcohol consumption can raise blood pressure and should be limited or avoided. Step 4: Smoking and using low-tar cigarettes can still raise blood pressure and have other negative health effects. Step 5: Daily multivitamin supplements do not directly impact blood pressure control.

Correct Answer: C

Rationale: The correct answer is C: Hematuria. Bacillus Calmette-Guerin (BCG) is a type of immunotherapy used to treat bladder cancer by stimulating the immune system to attack cancer cells. One common side effect of BCG instillations is hematuria, which is the presence of blood in the urine. This occurs because BCG irritates the bladder lining, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware and can report any excessive bleeding to their healthcare provider promptly. Other choices are incorrect: A: Renal calculi - BCG therapy is not known to cause renal calculi. B: Delayed ejaculation - BCG therapy is not associated with delayed ejaculation. D: Impotence - BCG therapy is not linked to impotence.

Correct Answer: A

Rationale: The correct answer is A: Phagocytosis. Macrophages and neutrophils are both types of phagocytes responsible for engulfing and digesting pathogens such as bacteria. This process helps in clearing infections and maintaining immune homeostasis. Summary: - Choice B (Complement fixation) is incorrect as it refers to a process where complement proteins bind to pathogens to enhance their removal by phagocytes. - Choice C (Antibody production) is incorrect as macrophages and neutrophils do not produce antibodies. They mainly rely on phagocytosis for pathogen clearance. - Choice D (Suppression of autoimmunity) is incorrect as these cells are involved in innate immunity and do not play a direct role in regulating autoimmunity.

Correct Answer: C

Rationale: Rationale: 1. Loratadine is typically dosed once daily, not twice daily, for allergic rhinitis. 2. Taking it twice daily may increase the risk of side effects without added benefit. 3. The client's dosing schedule reflects a misunderstanding of the medication regimen. 4. Option A is incorrect because loratadine is available in 10mg tablets. 5. Option B is incorrect as loratadine can be taken with or without food. 6. Option D is incorrect as Claritin is a common trade name for loratadine.

Correct Answer: A

Rationale: The correct answer is A: 7.35-7.45. Plasma pH typically falls within this range for normal clients. A pH of 7.35-7.45 indicates a slightly alkaline to neutral environment, which is essential for various physiological processes to function optimally. Choices B, C, and D have pH values outside the normal range, indicating either acidic (B and C) or highly alkaline (D) conditions, which would be abnormal and potentially harmful to the body's functioning. Therefore, the normal range for plasma pH is crucial to maintain homeostasis and support overall health.

Correct Answer: A

Rationale: The correct answer is A: Teaches proper handwashing technique. This is the most appropriate intervention because proper handwashing can help prevent the spread of infection, including urinary infections. Teaching the patient about handwashing empowers them to take control of their own hygiene, reducing the risk of infection. Summary of why other choices are incorrect: B: Properly cleans the patient's toilet - While important for maintaining cleanliness, this does not directly address the patient's risk for a urinary infection. C: Transports urine specimen to the lab - This is not a direct care intervention for preventing urinary infections. D: Informs the oncoming nurse during hand-off - Hand-off communication is important for continuity of care but does not directly address the patient's risk for a urinary infection.

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to share any additional information they may have forgotten or overlooked, ensuring a thorough health history interview. Choice A is incorrect as it implies the interviewer is unprepared or disinterested. Choice C is inappropriate as it may make the patient feel guilty or inadequate. Choice D is incorrect as it does not address the possibility of gathering more relevant information from the patient.