Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection?
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Solution
Hypertension
Option C: Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection.
A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?
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Solution
Encourage the client to perform pursed-lip breathing.
Option A: Pursed lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing.
Nurse Derek is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason?
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Solution
Decreased visual, auditory, and gustatory abilities.
Option B: Gradual loss of sight, hearing, and taste interferes with normal functioning.
Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective?
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Solution
The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
Option B: A walker needs to be picked up, placed down on all legs.
An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?
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Solution
Ask the woman’s family to provide personal items such as photos or mementos.
Option A: Photos and mementos provide visual stimulation to reduce sensory deprivation.
Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective?
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Solution
The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.
Option C: The cane acts as a support and aids in weight bearing for the weaker right leg.
Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first?
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Solution
Warm the dialysate solution.
Option B: Cold dialysate increases discomfort. The solution should be warmed to body temperature in warmer or heating pad; don’t use microwave oven.
Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?
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Solution
Use comfort measures and pillows to position the client.
Option D: Using comfort measures and pillows to position the client is a non-pharmacological methods of pain relief.
Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed?
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Solution
The client spontaneously flexes his wrist when the blood pressure is obtained.
Option C: Carpal spasms indicate hypocalcemia.
Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first?
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Solution
A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.
Option D: The client is at risk for peritonitis; should be assessed for further symptoms and infection.