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,A 69-year-old client is undergoing his second exchange of intermittent peritoneal
dialysis. Which of the following findings would require an immediate nursing
intervention?
a. The client complains of pain during the inflow of the dialysate
b. The client complains of constipation
c. The dialysate outflow is cloudy
d. There is blood-tinged fluid around the intra-abdominal catheter
✔️ Correct Answer: C
Rationale:
Cloudy dialysate outflow is a classic sign of peritonitis, a serious complication of
peritoneal dialysis that requires immediate intervention including antibiotic
therapy and possibly catheter removal. Pain during inflow is common during initial
exchanges and may be managed by slowing the infusion rate. Constipation is a
manageable side effect. Blood-tinged fluid around the catheter site may occur
normally but should be monitored; it does not require immediate intervention
compared to signs of infection.
The clinic nurse is performing dietary teaching with a 67-year-old client diagnosed
with acute gout. The nurse should instruct the client to limit intake of which of the
following foods?
a. Red meat and shellfish
b. Cottage cheese and ice cream
c. Fruit juices and milk
d. Fresh fruits and uncooked vegetables
✔️ Correct Answer: A
Rationale:
Red meat and shellfish are high in purines, which are metabolized to uric acid and
can exacerbate gout symptoms. Clients with gout should limit purine-rich foods to
reduce uric acid levels and prevent acute attacks. Dairy products (Option B) are
actually recommended as they may help lower uric acid levels. Fruit juices and milk
(Option C) are not typically restricted. Fresh fruits and vegetables (Option D) are
generally encouraged in a gout-friendly diet.
,A client is scheduled for a left lower lobectomy and the physician has ordered
diazepam 2 mg IM for preoperative anxiety. The nurse would determine the
medication is appropriate if the client displays which of the following symptoms?
a. Agitation and decreased level of consciousness
b. Lethargy and decreased respiratory rate
c. Restlessness and increased heart rate
d. Hostility and increased blood pressure
✔️ Correct Answer: C
Rationale:
Restlessness and increased heart rate are signs of anxiety that indicate the need for
a benzodiazepine such as diazepam. This medication is appropriate for preoperative
anxiety management. Agitation with decreased LOC (Option A) may indicate other
issues. Lethargy and decreased respiratory rate (Option B) are signs of oversedation
and would contraindicate further administration. Hostility and increased blood
pressure (Option D) may require different interventions.
A 59-year-old woman with bipolar disorder is receiving haloperidol 2 mg PO three
times daily. She tells the nurse, "Milk is coming out of my breasts." Which response
by the nurse is best?
a. "You are seeing things that aren't real"
b. "Why don't we go make some fudge"
c. "You are experiencing a side effect of Haldol"
d. "I'll contact your physician to change your medication"
✔️ Correct Answer: C
Rationale:
Galactorrhea (breast milk production) is a known side effect of haloperidol due to
its dopamine-blocking effects that can increase prolactin levels. The nurse should
provide factual information about the medication side effect. Option A dismisses
the client's valid concern. Option B is dismissive and nontherapeutic. Option D is
premature without first assessing the situation and notifying the provider after
providing education.
The physician orders ranitidine hydrochloride 150 mg PO daily for a client. The
nurse should advise the client that the best time to take this medication is:
, a. Before breakfast
b. With dinner
c. With food
d. At bedtime
✔️ Correct Answer: D
Rationale:
Ranitidine (Zantac) is a histamine-2 receptor antagonist that reduces gastric acid
secretion. Taking it at bedtime (hs) is recommended because gastric acid secretion
is highest at night, and this timing provides optimal suppression of nocturnal acid
production. While it can be taken with or without food, bedtime administration is
most effective for many clients.
If a client develops cor pulmonale (right-sided heart failure), the nurse would
expect to observe which of the following?
a. Increasing respiratory difficulty seen with exertion
b. Cough productive of a large amount of thick, yellow mucus
c. Peripheral edema and anorexia
d. Twitching of extremities
✔️ Correct Answer: C
Rationale:
Cor pulmonale (right-sided heart failure) results in peripheral edema due to fluid
retention and anorexia due to venous congestion of the gastrointestinal tract.
Option A is associated with left-sided heart failure. Option B is associated with
respiratory infections. Option D is associated with electrolyte imbalances.
The nurse is performing triage in the emergency department. Which client should
the nurse see first?
a. A 12-year-old oozing blood from a laceration of the left thumb due to a cut on a
rusty metal can
b. A 19-year-old with a fever of 103.8°F who is able to identify her sister but not the
place and time
c. A 49-year-old with a compound fracture of the right leg complaining of severe
pain