A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?

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Question 1 of 5

A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?

Correct Answer: C

Rationale: The correct answer is C: Potassium level of 6.5 mEq/L. High potassium levels in ESRD patients can lead to life-threatening cardiac arrhythmias. Immediate action is needed to prevent complications. A: Weight gain may indicate fluid retention, but it's not an immediate concern. B: Blood pressure is elevated but not an urgent issue. D: Hemoglobin level of 10 g/dL is within the acceptable range for ESRD patients and does not require immediate action.

Question 2 of 5

A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?

Correct Answer: C

Rationale: The correct answer is C: Assessing for signs of bleeding. This is the priority assessment because heparin therapy increases the risk of bleeding. Signs of bleeding include bruising, petechiae, blood in urine or stool, and excessive bleeding from wounds. Monitoring blood pressure (A) is important but not the priority in this situation. Checking aPTT (B) is important for evaluating the effectiveness of heparin therapy but does not take precedence over assessing for bleeding. Measuring calf circumference (D) is used to detect changes in calf size due to DVT but is not the priority assessment while the client is on heparin therapy.

Question 3 of 5

A healthcare professional is assessing a client with rheumatoid arthritis. Which assessment finding is most characteristic of this disease?

Correct Answer: C

Rationale: The correct answer is C: Morning stiffness lasting more than 30 minutes. This is characteristic of rheumatoid arthritis due to the inflammatory nature of the disease. The prolonged morning stiffness is a hallmark feature, reflecting the systemic inflammation present in rheumatoid arthritis. This symptom is not typically seen in osteoarthritis, which rules out options A and B. Pain that worsens with activity is more indicative of osteoarthritis as opposed to rheumatoid arthritis, making option D incorrect.

Question 4 of 5

A client with a history of gastrointestinal bleeding is taking warfarin (Coumadin). Which instruction should the nurse include in the teaching plan?

Correct Answer: C

Rationale: The correct answer is C: Report any signs of bruising or bleeding to your healthcare provider. This instruction is crucial because warfarin can increase the risk of bleeding, especially in clients with a history of gastrointestinal bleeding. Reporting any signs of bruising or bleeding promptly allows for timely intervention to prevent serious complications. A: Avoiding foods high in vitamin K is not necessary, as consistent intake of vitamin K-containing foods can help maintain stable anticoagulant levels. B: Taking aspirin along with warfarin can increase the risk of bleeding and should be avoided. D: Limiting fluid intake is not directly related to the management of warfarin therapy or gastrointestinal bleeding.

Question 5 of 5

When caring for a client with pneumonia, what intervention is most effective in preventing the spread of infection?

Correct Answer: D

Rationale: The correct answer is D because performing hand hygiene before and after client contact is crucial in preventing the spread of infection in pneumonia. This intervention helps in reducing the transmission of infectious agents from one client to another and from surfaces to clients. It is a fundamental infection control measure that minimizes the risk of spreading pathogens. Option A is important for treating the infection but does not directly prevent its spread. Option B is a good practice to contain respiratory secretions but may not be as effective as hand hygiene. Option C isolates the client but does not address the primary mode of transmission through contaminated hands.

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