a nurse is assessing a client with chronic kidney disease which of the following findings should the nurse monitor
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PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A nurse is assessing a client with chronic kidney disease. Which of the following findings should the nurse monitor?

Correct answer: B

Rationale: The correct answer is B: Fluid overload. Clients with chronic kidney disease are prone to fluid overload due to impaired kidney function. The kidneys may not effectively regulate fluid balance, leading to fluid retention. Monitoring for signs of fluid overload, such as edema, hypertension, and shortness of breath, is crucial. Choice A, Hypokalemia, is less likely in chronic kidney disease as the kidneys often have difficulty excreting potassium, leading to hyperkalemia. Decreased blood pressure (Choice C) is not a common finding in chronic kidney disease unless complications like volume depletion occur. Increased appetite (Choice D) is not typically associated with chronic kidney disease; in fact, many clients may experience a decreased appetite due to various factors such as uremia and dietary restrictions.

2. A client with osteoporosis is being taught by a nurse about dietary changes. Which of the following food choices should the nurse recommend to promote bone health?

Correct answer: C

Rationale: The correct answer is C: Fortified orange juice. Fortified orange juice is often supplemented with calcium and vitamin D, both of which are essential for bone health and the prevention of osteoporosis. Leafy green vegetables (choice A) are good for overall health but may not provide sufficient calcium for bone health. Red meat (choice B) is a source of protein but is not a primary source of calcium. Whole grains (choice D) are beneficial for fiber intake but do not contain significant amounts of calcium or vitamin D necessary for bone health.

3. A healthcare professional is assessing a client with hepatic encephalopathy. Which of the following foods indicates understanding of dietary teaching?

Correct answer: C

Rationale: The correct answer is C: 'Rice with black beans.' Plant-based proteins such as beans are recommended for clients with hepatic encephalopathy to reduce ammonia production from animal proteins. Cottage cheese (choice A), tuna salad (choice B), and a three-egg omelet (choice D) are high in animal proteins, which can contribute to increased ammonia levels in hepatic encephalopathy, making them less suitable dietary choices for these clients.

4. A client with cholecystitis has been prescribed a low-fat diet. Which of the following meal selections by the client indicates understanding of the education?

Correct answer: D

Rationale: The correct answer is D. Roast turkey is a lean protein option suitable for a low-fat diet. Rice pilaf and green beans are also low in fat. Choices A, B, and C contain high-fat ingredients like gravy, cheese, cream, and ice cream, which are not suitable for a low-fat diet.

5. A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?

Correct answer: C

Rationale: Keeping the client’s neck in a midline position is essential when caring for a client with increased intracranial pressure (ICP) as it helps promote optimal blood flow and reduces the risk of further increasing ICP. Placing pillows behind the client’s head (Choice A) may not be recommended as it could potentially increase ICP. Putting the client in a Sims' position (Choice B) and maintaining hip flexion at a 90° angle (Choice D) are not directly related to managing increased ICP and are not the priority interventions in this situation.

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