A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

Questions 53

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Question 1 of 9

A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

Correct Answer: B

Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.

Question 2 of 9

After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly expressing a dislike for all healthcare providers and nurses. How should the nurse respond?

Correct Answer: C

Rationale: In this situation, the nurse should respond by calmly reassuring the client that the discomfort from the IV insertion will be temporary. By providing reassurance and addressing the client's concerns, the nurse can help reduce the client's apprehension and create a more supportive environment for the procedure.

Question 3 of 9

A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 9

The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 9

What is the most effective way to implement a teaching plan?

Correct Answer: A

Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.

Question 6 of 9

A client is in the radiology department at 0900 when the prescription for levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?

Correct Answer: D

Rationale: To maintain a therapeutic level of medication, the nurse should administer the missed dose as soon as possible and adjust the administration schedule to prevent dangerously high levels of the drug in the bloodstream (D). It is important to document the reason for the delayed dose. Contacting the healthcare provider and completing a medication variance form (A) may cause unnecessary delays. Notifying the charge nurse and completing an incident report (C) should be done after addressing the immediate medication administration issue. Administering the medication at 1300 and resuming the 0900 schedule the next day (B) could lead to suboptimal therapeutic levels and potential complications.

Question 7 of 9

A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

Correct Answer: B

Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.

Question 8 of 9

What intervention should the healthcare provider include in the plan of care for a client receiving treatment with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

Correct Answer: A

Rationale: When an Unna's paste boot is applied for leg ulcers due to chronic venous insufficiency, it is crucial to check the capillary refill of the toes on the lower extremity to ensure adequate circulation. The Unna's paste boot can become rigid after drying, potentially affecting circulation distally. Monitoring capillary refill helps assess the perfusion status of the distal extremity and ensures that the treatment is not compromising circulation to the toes.

Question 9 of 9

The nurse is preparing a client for surgery. What action is most important for the nurse to take?

Correct Answer: A

Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.

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