Question

A client who receives hemodialysis three times a week is on a prescribed fluid restriction of 1000 mL per day. During a home visit, the nurse observes the client drinking a 355 mL (12 oz) soft drink, even though the client has already consumed their daily fluid allowance. What is the most appropriate action for the nurse to take?

Answer 1

Correct Answers:

Discuss with the client the importance of fluid restrictions and explore barriers to adherence.

Rationale :

🌹 Discussing the importance of fluid restriction and exploring barriers to adherence is the best action because it uses a therapeutic, patient-centered approach to address the client’s behavior.

🌹 Clients receiving hemodialysis have limited kidney function and cannot effectively remove excess fluid, making fluid restrictions essential to prevent complications such as fluid overload, hypertension, pulmonary edema, and heart failure.

🌹 The nurse should first assess why the client exceeded the prescribed 1000 mL/day fluid allowance, such as thirst, misunderstanding of restrictions, lifestyle challenges, or lack of coping strategies.

🌹 Exploring barriers allows the nurse to provide individualized education and develop realistic strategies for maintaining fluid control.

🌹 A nonjudgmental discussion improves trust and adherence because clients are more likely to share difficulties when they feel supported rather than criticized.

🌹 The nurse can teach methods such as using small cups, tracking all fluid intake, limiting salty foods that increase thirst, and using ice chips if permitted.

🌹 The goal is to help the client understand the consequences of excess fluid while promoting self-management of chronic kidney disease.

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Answer 2

Correct Answers:

Airborne

Rationale :

✍️ Airborne precautions are required for a client with tuberculosis (TB) because TB is caused by Mycobacterium tuberculosis, which spreads through airborne droplet nuclei that can remain suspended in the air.

✍️ A client with active tuberculosis and a productive cough can release infectious particles when coughing, sneezing, or speaking.

✍️ Airborne isolation requires placement in an airborne infection isolation room (negative-pressure room) to prevent contaminated air from spreading to other areas.

✍️ Healthcare workers should wear an appropriately fitted N95 respirator or higher-level respiratory protection when entering the room.

✍️ The client should wear a surgical mask during transport outside the isolation room to reduce transmission risk.

✍️ Airborne precautions are used for diseases such as tuberculosis, measles, varicella (chickenpox), and disseminated herpes zoster.

✍️ Initiating the correct isolation method protects other clients, healthcare workers, and visitors from infection exposure.

✍️ Therefore, the nurse should initiate airborne isolation precautions.

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Answer 3

Correct Answers:

Prepare for urgent thrombolytic therapy.

Rationale :

🧿 Preparing for urgent thrombolytic therapy is the priority because the client’s findings strongly indicate a massive pulmonary embolism (PE).

🧿 A history of deep vein thrombosis (DVT) places the client at high risk for a clot traveling from the lower extremities to the pulmonary arteries.

🧿 The symptoms of sudden chest pain, dyspnea, hemoptysis, tachycardia, and hypotension are classic signs of a significant pulmonary embolism causing impaired blood flow through the lungs.

🧿 After providing supplemental oxygen, the next priority is restoring pulmonary circulation and preventing cardiovascular collapse.

🧿 Thrombolytic medications dissolve the obstructing clot and are used for clients with severe PE causing hemodynamic instability, such as hypotension.

🧿 Rapid treatment is essential because a large embolus can decrease cardiac output and lead to obstructive shock or death.

🧿 The nurse should prepare emergency medications and interventions while continuing to monitor oxygenation, vital signs, and cardiac status.

🧿 Therefore, the next priority action is to prepare for urgent thrombolytic therapy.

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Answer 4

Correct Answers:

Assessing abdominal girth and fluid status

Rationale :

🖊️ Assessing abdominal girth and fluid status is the first action because the nurse must collect baseline data before implementing treatments for ascites.

🖊️ Ascites is the accumulation of fluid in the peritoneal cavity, commonly associated with liver cirrhosis and portal hypertension.

🖊️ Measuring abdominal girth, daily weight, intake and output, edema, and vital signs helps determine the severity of fluid accumulation and changes over time.

🖊️ Assessment allows the nurse to identify complications such as fluid overload, respiratory compromise, and worsening abdominal distention.

🖊️ According to the nursing process (assessment before intervention), the nurse should first determine the client’s current condition before initiating therapies.

🖊️ Accurate assessment findings guide decisions regarding treatments such as diuretics, dietary changes, or paracentesis.

🖊️ Establishing a baseline also helps evaluate whether future interventions are effective in reducing fluid retention.

🖊️ Therefore, the nurse should first assess abdominal girth and fluid status.

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Answer 5

Correct Answers:

The 72-year-old client who was transferred 2 hours ago from the ICU following a coronary artery bypass graft and has new-onset atrial fibrillation with rapid ventricular response.

Rationale :

🖊️ The client with new-onset atrial fibrillation (AFib) with rapid ventricular response (RVR) should be assessed first because this is an acute, potentially life-threatening cardiac rhythm problem.

🖊️ After a coronary artery bypass graft (CABG), new dysrhythmias such as AFib can occur and may significantly reduce cardiac output.

🖊️ AFib with RVR causes the ventricles to beat too rapidly, reducing the time available for ventricular filling and decreasing effective blood flow to the body.

🖊️ The nurse should immediately assess heart rate, blood pressure, oxygen saturation, level of consciousness, chest pain, and signs of decreased perfusion.

🖊️ The priority framework of airway, breathing, circulation (ABC) and unstable versus stable conditions requires attention to clients with active cardiovascular instability first.

🖊️ Unlike chronic conditions or expected postoperative findings, a new rapid rhythm change can quickly progress to hypotension, ischemia, heart failure, or stroke.

🖊️ Early recognition allows timely interventions such as medication therapy, rate control, rhythm management, or cardioversion if indicated.

🖊️ Therefore, the nurse should first assess the client with new-onset atrial fibrillation with rapid ventricular response after CABG.

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Answer 6

Correct Answers:

Blood pressure monitoring for hypertension

Rationale :

🏵️ Assessing for signs of infection is the priority because Cushing’s syndrome causes excessive cortisol levels, which suppress the immune system and increase the risk of serious infections.

🏵️ Elevated cortisol decreases the body’s inflammatory response and reduces the ability of white blood cells to fight pathogens.

🏵️ Clients with Cushing’s syndrome may have infections that are difficult to recognize because the normal signs of inflammation, such as fever and redness, may be reduced.

🏵️ Untreated infections can rapidly progress to sepsis and life-threatening complications, making infection monitoring a priority.

🏵️ The nurse should assess for subtle signs such as fatigue, changes in wound appearance, elevated temperature, drainage, or increased glucose levels.

🏵️ Although Cushing’s syndrome also causes hypertension, hyperglycemia, and electrolyte abnormalities, infection risk represents a major threat due to impaired immunity.

🏵️ Early identification of infection allows prompt treatment and reduces the risk of severe complications.

🏵️ Therefore, the nurse should prioritize assessing for signs of infection.

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Answer 7

Correct Answers:

Abdominal distension and rigidity

Rationale :

♦️ Abdominal distension and rigidity are priority findings because they may indicate a serious complication of acute pancreatitis, such as peritonitis, paralytic ileus, hemorrhage, or worsening inflammation.

♦️ Acute pancreatitis causes enzymatic inflammation of the pancreas, and severe inflammation can spread to surrounding tissues, causing irritation of the peritoneum.

♦️ A rigid abdomen is an abnormal finding that suggests involuntary guarding, which may indicate a surgical abdomen or significant intra-abdominal complication.

♦️ Abdominal distension can occur due to decreased intestinal motility, fluid accumulation, inflammation, or ileus associated with severe pancreatitis.

♦️ These findings require immediate reporting because they may signal deterioration and increased risk for shock, organ failure, or systemic inflammatory response syndrome (SIRS).

♦️ The nurse should perform additional assessments, including vital signs, pain evaluation, bowel sounds, and signs of hemodynamic instability.

♦️ Early recognition of complications allows prompt medical intervention and may prevent progression to life-threatening conditions.

♦️ Therefore, the nurse should prioritize and immediately report abdominal distension and rigidity.

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Answer 8

Correct Answers:

Notify the provider of the client's manifestations

Rationale :

🧿 Notify the provider of the client's manifestations is the priority because the client receiving tacrolimus after a liver transplant is immunosuppressed and at increased risk for infection.

🧿 A persistent dry cough and temperature of 100.8°F (38.2°C) are concerning findings that may indicate an infection, which can become serious in a transplant recipient.

🧿 Tacrolimus works by suppressing the immune response to prevent organ rejection, but this also reduces the body's ability to fight infections.

🧿 Transplant clients require prompt evaluation of fever, respiratory symptoms, and other infection signs because infections can progress rapidly.

🧿 The nurse should not assume these findings are expected medication effects because fever is not a normal therapeutic response to tacrolimus.

🧿 The provider may need to evaluate the client, order diagnostic testing, review medication levels, and determine appropriate treatment.

🧿 Early identification and management of infection helps protect the transplanted organ and prevents life-threatening complications.

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Answer 9

Correct Answers:

Hyperglycemia

Rationale :

🌼 Hyperglycemia is the correct answer because corticosteroids increase blood glucose levels by promoting gluconeogenesis (production of glucose by the liver) and reducing the effectiveness of insulin.

🌼 Clients receiving corticosteroids for respiratory conditions, such as asthma or COPD exacerbations, are at risk for elevated blood glucose even if they do not have a history of diabetes.

🌼 Corticosteroids decrease cellular glucose uptake, causing glucose to remain in the bloodstream and resulting in steroid-induced hyperglycemia.

🌼 The nurse should monitor blood glucose levels in clients receiving corticosteroids, especially those receiving high doses or prolonged therapy.

🌼 Signs of hyperglycemia may include increased thirst, frequent urination, fatigue, and blurred vision.

🌼 Corticosteroids can also increase the risk of infection because they suppress the immune response, making monitoring important.

🌼 Early recognition of elevated glucose allows timely intervention and helps prevent complications such as dehydration and poor wound healing.

🌼 Therefore, the client receiving corticosteroids is at increased risk for hyperglycemia.

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Answer 10

Correct Answers:

Decrease the oxygen concentration level and monitor the client's respiratory rate/effort.

Rationale :

🌻 Decreasing the oxygen concentration level and monitoring respiratory status is the priority action because the client is showing possible signs of oxygen toxicity after receiving supplemental oxygen for an extended period.

🌻 Oxygen toxicity occurs when prolonged exposure to high oxygen concentrations causes oxidative damage to lung tissue.

🌻 Early manifestations of oxygen toxicity include substernal chest pain, dry cough, difficulty breathing, and decreased lung function.

🌻 The nurse should reduce the oxygen concentration to the lowest level needed to maintain adequate oxygenation while continuing to monitor the client closely.

🌻 Monitoring respiratory rate, depth, effort, and oxygen saturation helps determine whether the client is maintaining effective gas exchange after reducing oxygen therapy.

🌻 The goal of oxygen therapy is to correct hypoxemia, not to provide unnecessarily high oxygen levels that may cause injury.

🌻 Prompt recognition and adjustment of oxygen therapy can prevent progression to more severe complications such as pulmonary inflammation and respiratory failure.

🌻 Therefore, the nurse should decrease the oxygen concentration level and monitor the client's respiratory rate and effort.

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QLexNursing

2 :
A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

4 :
A nurse on the medical-surgical unit is performing an assessment on a client with ascites. What action should the nurse take first?

5 :
A nurse who is beginning a shift receives report on four clients. Which client should the nurse assess first?

6 :
A nurse is caring for a client diagnosed with Cushing's syndrome. Which clinical parameter should the nurse prioritize monitoring to reduce the risk of life-threatening complications?

7 :
A client with acute pancreatitis is admitted to the medical-surgical floor. Which assessment finding should the nurse prioritize and report immediately?

8 :
A nurse is caring for a client who is receiving tacrolimus following a liver transplant.

Answer Options

9 :
A client is prescribed corticosteroids for an acute respiratory condition. The nurse understands the client is at an increased risk for which of the following conditions?

10 :
A client who has been receiving supplemental oxygen therapy for an extended period begins experiencing substernal chest pain and dry cough. What priority action should the nurse take to prevent further complications of oxygen toxicity?

QLexNursing

2 : A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

4 : A nurse on the medical-surgical unit is performing an assessment on a client with ascites. What action should the nurse take first?

5 : A nurse who is beginning a shift receives report on four clients. Which client should the nurse assess first?

6 : A nurse is caring for a client diagnosed with Cushing's syndrome. Which clinical parameter should the nurse prioritize monitoring to reduce the risk of life-threatening complications?

7 : A client with acute pancreatitis is admitted to the medical-surgical floor. Which assessment finding should the nurse prioritize and report immediately?

8 : A nurse is caring for a client who is receiving tacrolimus following a liver transplant.

Answer Options

9 : A client is prescribed corticosteroids for an acute respiratory condition. The nurse understands the client is at an increased risk for which of the following conditions?

10 : A client who has been receiving supplemental oxygen therapy for an extended period begins experiencing substernal chest pain and dry cough. What priority action should the nurse take to prevent further complications of oxygen toxicity?

2 :
A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

4 :
A nurse on the medical-surgical unit is performing an assessment on a client with ascites. What action should the nurse take first?

5 :
A nurse who is beginning a shift receives report on four clients. Which client should the nurse assess first?

6 :
A nurse is caring for a client diagnosed with Cushing's syndrome. Which clinical parameter should the nurse prioritize monitoring to reduce the risk of life-threatening complications?

7 :
A client with acute pancreatitis is admitted to the medical-surgical floor. Which assessment finding should the nurse prioritize and report immediately?

8 :
A nurse is caring for a client who is receiving tacrolimus following a liver transplant.

9 :
A client is prescribed corticosteroids for an acute respiratory condition. The nurse understands the client is at an increased risk for which of the following conditions?

10 :
A client who has been receiving supplemental oxygen therapy for an extended period begins experiencing substernal chest pain and dry cough. What priority action should the nurse take to prevent further complications of oxygen toxicity?