A nurse is planning care for a client who is receiving hemodialysis via an AV fistula. Which of the following interventions should the nurse include in the plan of care?

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Question 1 of 5

A nurse is planning care for a client who is receiving hemodialysis via an AV fistula. Which of the following interventions should the nurse include in the plan of care?

Correct Answer: A

Rationale: The correct intervention is to avoid taking blood pressures on the arm with the AV fistula. This is crucial to prevent complications such as damage to the fistula. Checking the fistula site for pallor is not as important as avoiding blood pressures on the affected arm. Placing warm compresses over the fistula site is not recommended as it can increase the risk of infection. Keeping the client's arm elevated on two pillows is not necessary for the care of an AV fistula.

Question 2 of 5

A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?

Correct Answer: B

Rationale: The correct answer is B because administering insulin lispro to an NPO client can lead to hypoglycemia due to the lack of food to balance the medication. This situation poses a serious risk to the client's safety and should be documented in an incident report. Choice A is not as critical as insulin administration for an NPO client. Choice C is also serious but does not pose an immediate risk to the client's health. Choice D, administering anticoagulants without checking the INR, is important but does not require an incident report unless adverse effects occur, as it may not immediately endanger the client's life.

Question 3 of 5

A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

Correct Answer: D

Rationale: The correct answer is D because rinsing the mouth is essential to prevent staining and irritation caused by ferrous sulfate elixir. Choices A, B, and C are incorrect. Taking ferrous sulfate elixir before meals (Choice A) is not necessary. Mixing it with water (Choice B) is not recommended as it may alter the medication's effectiveness. Taking the medication once a week (Choice C) is incorrect as ferrous sulfate is usually prescribed daily or as directed by a healthcare provider.

Question 4 of 5

A healthcare professional is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the healthcare professional expect the provider to prescribe for the client?

Correct Answer: C

Rationale: Chlordiazepoxide is a benzodiazepine commonly used to manage anxiety and prevent seizures during alcohol withdrawal. Haloperidol (Choice A) is an antipsychotic medication and is not typically used for alcohol withdrawal. Disulfiram (Choice B) is used in the treatment of alcohol use disorder but is not indicated for alcohol withdrawal. Phenobarbital (Choice D) may be used for alcohol withdrawal seizures but is not the first-line medication for managing alcohol withdrawal symptoms.

Question 5 of 5

A nurse is caring for a client who requests information about advance directives. Which of the following responses should the nurse make?

Correct Answer: C

Rationale: The correct response is C: 'It includes end-of-life care instructions.' An advance directive is a legal document that outlines a client's preferences for medical treatment and end-of-life care in case they are unable to communicate. Choice A is incorrect because an advance directive focuses on healthcare decisions, not funeral arrangements. Choice B is incorrect as organ donation is a separate process from advance directives. Choice D is incorrect as advance directives do not provide legal guardianship rights, but rather specify healthcare wishes.

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