a client in end stage renal disease is receiving peritoneal dialysis at home the nurse must educate the client about potential complications associat

NCLEX-RN

NCLEX RN Prioritization Questions

1. A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:

A. Hypotriglyceridemia
B. Abdominal hernia
C. Anorexia
D. Peritonitis

Correct answer: A

Rationale: Peritoneal dialysis poses risks of various complications, including abdominal hernia, anorexia, peritonitis, and other issues. However, hypotriglyceridemia is not a common complication associated with peritoneal dialysis. The nurse should focus on educating the client about the risks of developing peritonitis, abdominal hernias, anorexia, low back pain, and abdominal bleeding. Monitoring triglyceride levels is essential for managing lipid disorders but is not directly linked to peritoneal dialysis complications.

2. The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?

A. Hepatitis testing
B. Tuberculosis screening
C. Contraceptive teaching
D. Colonoscopy information

Correct answer: B

Rationale: Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.

3. A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, being hot to the touch, sitting leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?

A. Prepare the child for an X-ray of the upper airways
B. Examine the child's throat
C. Collect a sputum specimen
D. Notify the healthcare provider of the child's status

Correct answer: D

Rationale: The correct initial action is to notify the healthcare provider of the child's status. The presenting symptoms described, such as irritability, thick muffled voice, croaking on inspiration, being hot to the touch, sitting leaning forward, tongue protruding, drooling, and suprasternal retractions, are indicative of epiglottitis, a potentially life-threatening condition. Immediate medical attention is crucial in such cases. While preparing for an X-ray or examining the throat may be necessary, the priority is to ensure prompt evaluation and intervention by the healthcare provider. Collecting a sputum specimen is not relevant in this situation and would cause unnecessary delay. Therefore, the nurse should prioritize communication with the healthcare provider to expedite appropriate management and treatment.

4. While taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer, the nurse learns that the patient is complaining of epigastric pain. What assessment finding would the nurse expect to note?

A. Melena
B. Nausea
C. Hernia
D. Hyperthermia

Correct answer: A

Rationale: Melena is the passage of black, tarry stools due to the presence of blood in the gastrointestinal tract, usually originating from the upper digestive system. In the context of a Duodenal Ulcer, melena can occur as a result of bleeding in the duodenum or the upper part of the small intestine. This finding is significant as it indicates potential gastrointestinal bleeding, which is a common complication of duodenal ulcers. Nausea (Choice B) is a nonspecific symptom that may be present with various gastrointestinal conditions but is not specific to duodenal ulcers. Hernia (Choice C) involves the protrusion of an organ through the wall of the cavity that normally contains it and is not directly related to the symptoms of a duodenal ulcer. Hyperthermia (Choice D), which refers to an elevated body temperature, is not typically associated with duodenal ulcers unless there are severe complications present.

5. Mr. B is recovering from a surgical procedure that was performed four days ago. The nurse's assessment finds this client coughing up rust-colored sputum; his respiratory rate is 28/minute with expiratory grunting, and his lung sounds have coarse crackles on auscultation. Which of the following conditions is the most likely cause of these symptoms?

A. Tuberculosis
B. Pulmonary edema
C. Pneumonia
D. Histoplasmosis

Correct answer: C

Rationale: In this scenario, the client's presentation of coughing up rust-colored sputum, increased respiratory rate, expiratory grunting, and coarse crackles on lung auscultation suggests the development of pneumonia. Pneumonia is characterized by lung tissue inflammation or infection, often caused by various organisms. Symptoms may include productive cough, dyspnea, and abnormal breath sounds. Tuberculosis (Choice A) typically presents with a chronic cough, weight loss, and night sweats and is less likely in this acute post-operative setting. Pulmonary edema (Choice B) is characterized by pink, frothy sputum, crackles throughout the lungs, and typically occurs in the context of heart failure. Histoplasmosis (Choice D) is a fungal infection that usually presents with flu-like symptoms and is less likely to manifest with the specific respiratory findings described in this case.