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 :

🧭A therapeutic discussion allows the nurse to identify why the client exceeded the prescribed restriction.

💧Excess fluid intake between treatments can cause fluid overload, hypertension, edema, and increased cardiac stress.

🗣️Exploring thirst, sodium intake, routines, understanding, and available support helps create realistic strategies for adherence.

🤝This patient-centered response respects client autonomy and is more likely to improve long-term behavior.

📌Core Message

The nurse should use patient-centered education to identify barriers and improve adherence to the fluid restriction.

Answer 2

Correct Answers:

Airborne

Rationale :

🌬️Pulmonary tuberculosis spreads through microscopic airborne droplet nuclei released when an infected person coughs, speaks, or sings.

🦠These particles can remain suspended in the air and travel beyond close-contact distances.

🏥The client should be placed in an airborne infection isolation room, preferably with negative pressure.

😷Healthcare personnel should wear a properly fitted N95 respirator or higher-level respiratory protection.

📌Core Message

Active pulmonary tuberculosis requires airborne precautions, a negative-pressure room, and an N95 respirator.

Answer 3

Correct Answers:

Prepare for urgent thrombolytic therapy.

Rationale :

🚨Sudden chest pain, dyspnea, hemoptysis, tachycardia, and a history of DVT strongly indicate an acute pulmonary embolism.

🫁The client’s hypotension indicates cardiopulmonary failure and hemodynamic instability, making the embolism immediately life-threatening.

📉Supplemental oxygen supports oxygenation but does not remove the pulmonary arterial obstruction.

💉Urgent thrombolytic therapy may rapidly dissolve the clot in eligible clients with PE-associated low blood pressure or life-threatening manifestations.

📌Core Message

A pulmonary embolism with hypotension requires immediate preparation for advanced clot-dissolving therapy after oxygen support.

Answer 4

Correct Answers:

Assessing abdominal girth and fluid status

Rationale :

📏The nurse should follow the assessment-before-intervention principle when caring for a client with ascites.

⚖️Abdominal girth, body weight, edema, intake and output, and respiratory status help determine the severity of fluid accumulation.

🩺Baseline findings allow the nurse to identify deterioration and evaluate the effectiveness of later treatment.

📝Diuretics, dietary changes, and paracentesis should be considered only after the client’s current clinical status is established.

📌Core Message

First assess abdominal girth and overall fluid status to establish a baseline and guide further ascites management.

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 :

❤️‍🔥New-onset atrial fibrillation with rapid ventricular response is an acute change that can rapidly compromise cardiac function.

📈The fast ventricular rate shortens filling time and can reduce stroke volume, coronary perfusion, and cardiac output.

⏱️The client recently underwent cardiac surgery, increasing the need for immediate assessment of hemodynamic stability and postoperative complications.

🫀Prompt assessment allows rapid initiation of rate control, rhythm management, or synchronized cardioversion when clinically indicated.

📌Core Message

A new rapid atrial dysrhythmia after cardiac surgery presents the most immediate risk of decreased cardiac output.

Answer 6

Correct Answers:

Monitoring electrolyte levels for hypokalemia

Rationale :

⚗️Excess cortisol can produce mineralocorticoid effects that increase renal potassium loss.

🧂A falling serum potassium level can interfere with normal cardiac electrical conduction.

⚠️Severe hypokalemia may cause muscle weakness, respiratory impairment, and potentially fatal ventricular dysrhythmias.

📊Frequent electrolyte monitoring permits early potassium replacement and prevention of an immediate cardiac complication.

📌Core Message

Prioritize potassium monitoring because severe hypokalemia can cause life-threatening cardiac dysrhythmias.

Answer 7

Correct Answers:

Abdominal distension and rigidity

Rationale :

🧱Abdominal rigidity indicates involuntary muscle contraction associated with peritoneal irritation.

🔥Distension combined with rigidity may signal severe pancreatic inflammation, ileus, peritonitis, hemorrhage, or an evolving acute abdomen.

🚑These complications can progress rapidly to organ failure, shock, or abdominal compartment syndrome and require immediate reporting.

🔬The nurse should promptly reassess vital signs, bowel sounds, pain, and signs of hemodynamic deterioration.

📌Core Message

Abdominal distension and rigidity may indicate a severe acute-abdominal complication requiring immediate evaluation.

Answer 8

Correct Answers:

Notify the provider of the client's manifestations

Rationale :

🤒Tacrolimus suppresses the immune system and increases the risk of serious opportunistic and bacterial infections.

😮‍💨A persistent cough with a temperature of 100.8°F may represent an infection in an immunosuppressed transplant recipient.

🧑‍⚕️The provider should be notified promptly so diagnostic testing, cultures, laboratory monitoring, and treatment can be initiated.

📞The provider must also determine whether the tacrolimus dose should be continued, held, or adjusted based on the client’s clinical and laboratory status.

📌Core Message

A transplant recipient taking tacrolimus who develops fever and cough requires prompt provider notification for possible infection.

Answer 9

Correct Answers:

Hyperglycemia

Rationale :

🍭Corticosteroids increase blood glucose levels through their metabolic effects.

⚙️They promote hepatic glucose production and reduce effective peripheral glucose utilization.

⬆️The resulting elevation may worsen existing diabetes or cause steroid-induced hyperglycemia in susceptible clients.

🧾The nurse should monitor blood glucose and assess for polyuria, polydipsia, blurred vision, and other manifestations of elevated glucose.

📌Core Message

Corticosteroids commonly increase blood glucose, placing the client at risk for hyperglycemia.

Answer 10

Correct Answers:

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

Rationale :

☣️Substernal chest discomfort and a dry cough after prolonged oxygen exposure are early findings of pulmonary oxygen toxicity.

🫧Excess oxygen produces oxidative injury, tracheobronchial inflammation, alveolar damage, and impaired gas exchange.

🎚️The inspired oxygen concentration should be reduced to the lowest level that maintains adequate oxygenation.

👁️The nurse should closely monitor respiratory rate, work of breathing, oxygen saturation, breath sounds, and signs of worsening pulmonary injury.

📌Core Message

Suspected oxygen toxicity requires reducing the inspired oxygen concentration and closely monitoring respiratory status.

📌Core Message

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?

📌Core Message

📌Core Message

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

📌Core Message

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

📌Core Message

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?

📌Core Message

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

📌Core Message

📌Core Message

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?

📌Core Message

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?

📌Core Message

📌Core Message

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?

📌Core Message

📌Core Message

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

📌Core Message

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

📌Core Message

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?

📌Core Message

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

📌Core Message

📌Core Message

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?

📌Core Message

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?

📌Core Message

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?

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?