The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?

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Question 1 of 5

The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer: C

Rationale: The correct answer is C because pain in the lower back may indicate a potential serious issue such as kidney problems or infection in the elderly. The kidneys are located in the lower back region, so pain in this area could be a sign of kidney dysfunction. The nurse should report this finding to the healthcare provider immediately for further evaluation and intervention. Choice A is incorrect because decreased urine output can be a common issue in older adults and may not always indicate a serious problem. Choice B is incorrect as loss of appetite can have various causes and may not be as urgent as lower back pain. Choice D is also incorrect as a persistent cough can have multiple causes, but it is not as concerning as potential kidney issues indicated by lower back pain in an older client.

Question 2 of 5

The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?

Correct Answer: C

Rationale: Rationale: Choice C is correct because sudden weight gain can indicate fluid retention, a common complication in chronic kidney disease. This can lead to serious issues like heart failure. Monitoring weight daily (A) is important, but specifically reporting significant gains promptly (C) is crucial. Limiting fluid intake (B) is important, but not the top priority. Increasing protein intake (D) may worsen kidney function, so it's not recommended.

Question 3 of 5

A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?

Correct Answer: D

Rationale: The correct answer is D because discarding the first morning specimen ensures accurate collection starts. Choice A is incorrect because refrigeration is unnecessary for a 24-hour urine collection. Choice B is incorrect as the first void should be included. Choice C is incorrect as there's no need to keep the urine on ice.

Question 4 of 5

A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client¢â‚¬â„¢s teaching plan?

Correct Answer: C

Rationale: The correct answer is C: Rotate insulin injection sites. This instruction is crucial to prevent lipohypertrophy, which can lead to inconsistent insulin absorption. By rotating injection sites, the client ensures proper insulin absorption and prevents complications. Checking blood glucose levels once a week (B) is not frequent enough for proper diabetes management. Avoiding all forms of sugar (A) is an outdated approach, as moderation is key. Monitoring urine ketone levels (D) is not as reliable as blood ketone testing for assessing diabetic ketoacidosis risk.

Question 5 of 5

The nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client. Which action is most important for the nurse to take?

Correct Answer: A

Rationale: The correct answer is A: Verify the client's blood type. This is crucial before administering PRBCs to prevent a potentially life-threatening transfusion reaction. Step 1: Check the blood type on the PRBCs label. Step 2: Verify the client's blood type against the label. Steps 3: Crossmatch the blood to ensure compatibility. Checking vital signs (C) is important but not the priority. Ensuring PRBCs are warm (B) is not necessary. Obtaining consent (D) is important but verifying blood type takes precedence to ensure safe transfusion.

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