The primary cause of anemia in clients with chronic renal failure is:
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Solution
Answer B is correct. The primary cause of anemia in the client with chronic renal failure is the lack of erythropoietin. Answer A is incorrect because it is not the primary cause of anemia in the client with chronic renal failure. Answer C is incorrect because it refers to sickle cell anemia. Answer D is incorrect because it refers to iron-deficiency anemia.
The physician has prescribed Phenergan (promethazine) with codeine for a client with pleurisy. The nurse recognizes that the medication was ordered for its:
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Solution
Answer C is correct. Phenergan with codeine is an antitussive that relieves coughing and affords the client an opportunity to rest. Answers A and B are not properties of the medication; therefore, they are incorrect. Answer D is incorrect because the amount of codeine in the medication is not sufficient to relieve pain.
The nurse is caring for a client following a colonoscopy in which conscious sedation was used. Initial assessment of the client reveals the following: BP 128/72, temperature 97, pulse 64, respirations 14, oxygen saturation 90%, and Glascow score of 13. An IV of normal saline is infusing at 20 drops per minute. Which nursing intervention should receive priority?
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Solution
Answer B is correct. The client’s oxygen saturation is low; therefore, the nurse should give priority to administering oxygen per standing order. Answer A is incorrect because there is nothing that indicates that the client needs an analgesic. Answer C is incorrect because the client’s temperature is satisfactory. Answer D is incorrect because the Glascow score of 13 indicates that the client is not fully recovered from the effects of conscious sedation; therefore, the IV should not be discontinued.
The nurse is caring for a client following an exploratory laparotomy. Which of the following assessment findings requires intervention?
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Solution
Answer B is correct. The hourly urinary output should be maintained between 30mL and 50mL per hour. The fact that the urine is dark amber indicates that the client is not receiving adequate fluids to prevent dehydration. Answers A, C, and D do not call for any interventions; therefore, they are incorrect.
The LPN is assigning tasks to the nursing assistant. Which task is beyond the scope of practice for the nursing assistant?
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Solution
Answer D is correct. The skill of aspirating nasogastric secretions is beyond the scope of practice of the nursing assistant. Answers A, B, and C are incorrect because they are within the scope of practice of the nursing assistant.
A 6-year-old is admitted with a diagnosis of leukemia. The most frequent presenting symptoms of leukemia include:
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Solution
Answer B is correct. Presenting symptoms of leukemia include pallor, fatigue, anorexia, petechiae, and bone or joint pain. Answers A, C, and D are incorrect because they are not associated with leukemia.
A 10-year-old received an injury to his face and mouth in a bicycle accident. Examination reveals that a permanent tooth has been evulsed. Emergency care following evulsion of a permanent tooth includes:
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Solution
Answer A is correct. The evulsed tooth should be rinsed in milk, in saline solution, or under running water before reimplantation. Answer B is incorrect because it will disturb the adhering periodontal membrane. Answer C is incorrect because the tooth should be held by the crown, not the root. Answer D is incorrect because the child might swallow or aspirate the tooth.
The nurse is preparing a client with Addison’s disease for discharge. The nurse should explain that the client can help prevent complications by:
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Solution
Answer D is correct. The client with Addison’s disease is treated with corticosteroid therapy that reduces the client’s immunity. The client needs to stay out of crowds to prevent complications posed by infection. Answers A and C are incorrect because the client needs additional sources of sodium and potassium in the diet. Answer B is incorrect because the client with Addison’s disease should dress in warm clothing to prevent easy chilling
The physician has ordered an injection of Demerol (meperidine) for a client with pancreatitis. The nurse should:
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Solution
Answer B is correct. The client with pancreatitis has decreased levels of vitamin K, making him more likely to have prolonged bleeding with injections; therefore, the nurse should hold pressure on the injection site for 3–5 minutes. Answer A is incorrect because the medication is not administered using the Z track method. Answer C is incorrect because the medication is not administered subcutaneously. Answer D is incorrect because alcohol, not betadine, is used to prep the skin.
The nurse is caring for a client with degenerative joint disease. Which finding is associated with degenerative joint disease?
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Solution
Answer A is correct. Degenerative joint disease (osteoarthritis) is characterized by joint pain that intensifies with activity and diminishes with rest. Answers B, C, and D are typical findings in the client with rheumatoid arthritis; therefore, they are incorrect.