Question 1: A nurse is caring for a client with end-stage renal disease (ESRD). The client reports severe itching. What is the most likely cause of this symptom?
Rationale: Uremia causes the accumulation of toxins in the blood, leading to pruritus (severe itching) in clients with ESRD.
Question 2: A nurse is teaching a client with a new prescription for nitroglycerin. Which statement indicates the need for further teaching?
Rationale: Nitroglycerin should not be taken with sildenafil due to the risk of severe hypotension.
Question 3: A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory result should the nurse monitor to evaluate the effectiveness of the therapy?
Rationale: The INR (International Normalized Ratio) is used to monitor the effectiveness of warfarin therapy and ensure therapeutic anticoagulation.
Question 4: A client with a nasogastric (NG) tube complains of nausea and abdominal distention. What is the nurse’s priority action?
Rationale: Checking the NG tube for patency is the priority to ensure it is functioning correctly and relieving gastric distention.
Question 5: A nurse is assessing a client with a chest tube. Which finding requires immediate intervention?
Rationale: A disconnected chest tube poses a risk of pneumothorax and requires immediate intervention to reestablish the system.
