the nurse is assessing a client with chronic renal failure who is receiving peritoneal dialysis which of the following findings would indicate a compl

HESI RN

HESI Medical Surgical Exam

1. The healthcare provider is assessing a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings would indicate a complication of the treatment?

A. Clear dialysate outflow.
B. Cloudy dialysate outflow.
C. Decreased urine output.
D. Increased blood pressure.

Correct answer: B

Rationale: Cloudy dialysate outflow is a sign of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Peritonitis, an infection of the peritoneum, the lining of the abdominal cavity, can lead to severe complications if not treated promptly. Clear dialysate outflow is an expected finding in peritoneal dialysis, indicating proper functioning of the process. Decreased urine output is common in clients with renal failure due to impaired kidney function. Increased blood pressure may be present in renal failure but is not a direct complication of peritoneal dialysis.

2. In a patient with pneumonia, what is the primary goal of treatment?

A. Reducing inflammation.
B. Eliminating the infection.
C. Reducing pain.
D. Preventing complications.

Correct answer: B

Rationale: The primary goal of treating pneumonia is to eliminate the infection. Antibiotics are commonly used to target the specific pathogen causing pneumonia. While reducing inflammation and preventing complications are important aspects of treatment, the key focus initially is on eradicating the infectious agent to improve the patient's condition and prevent further spread of the infection.

3. The patient is being educated on taking hydrochlorothiazide. Which statement by the patient indicates a need for further teaching?

A. I may need additional sodium and calcium while taking this medication.
B. I should consume plenty of fruits and vegetables while taking this drug.
C. I should be cautious when getting up from a bed or chair while on this medication.
D. I will take the medication in the morning to reduce certain side effects.

Correct answer: A

Rationale: The correct answer is A because patients do not require extra sodium or calcium while taking hydrochlorothiazide, a thiazide diuretic. This medication actually promotes the excretion of sodium and water. Choices B, C, and D are correct statements regarding the use of hydrochlorothiazide. Patients are encouraged to have a diet rich in fruits and vegetables, be careful with position changes due to potential orthostatic hypotension, and take the medication in the morning to reduce the need for frequent urination during nighttime.

4. The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

A. Protect the skin of the radiation portal site from sunlight exposure
B. Apply moisturizing lotions daily to the radiation portal site
C. Avoid washing the skin inside the radiation portal site
D. Remove the ink marks of the portal after each radiation treatment

Correct answer: A

Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.

5. A client with a history of type 1 diabetes Mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) of 325mg/dl (18mmol/L SI). The client describes to the nurse not understanding why the blood glucose level continues to be out of control. Which interventions should the nurse implement?

A. Have the client describe a typical day at work, home, and social activities
B. Determine if the client is using a new insulin needle for each administration
C. Evaluate the client's asthma medications that can elevate blood glucose
D. Have the client demonstrate the technique used to monitor blood glucose levels

Correct answer: A

Rationale: The correct answer is to have the client describe a typical day at work, home, and social activities. By understanding the client's daily routine, the nurse can gain valuable insights into lifestyle factors that may be impacting blood glucose control. This information is essential for identifying potential triggers or patterns contributing to the elevated blood sugar levels. Option B, determining if the client is using a new insulin needle for each administration, focuses more on the technical aspect of insulin delivery and is not directly related to daily activities affecting blood glucose levels. Option C, evaluating the client's asthma medications that can elevate blood glucose, could be relevant but is not as directly linked to the client's lifestyle choices as option A. Option D, having the client demonstrate the technique for monitoring blood glucose levels, is important for assessing their skills but does not provide information on daily activities that may be influencing blood sugar levels.