The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which intervention should the nurse perform?

Provide water for a client diagnosed with chronic kidney disease

Instruct the client on appropriate fluid restrictions

Measure the client's output from the indwelling catheter

Record the client’s intake and output in the EMR

Answer and Explanation

The Correct Answer is B

A. Provide water for a client diagnosed with chronic kidney disease: Fluid intake must be controlled in CKD. A nurse should determine if water intake is appropriate.

B. Instruct the client on appropriate fluid restrictions: Client education is a nursing responsibility and cannot be delegated to a UAP. The nurse should educate clients on fluid restrictions in conditions like chronic kidney disease (CKD) to prevent fluid overload and electrolyte imbalances.

C. Measure the client’s output from the indwelling catheter: This task can be delegated to a UAP.

D. Record the client’s intake and output in the EMR: UAPs can record I&O but cannot interpret the data.

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Correct Answer is D

Explanation

A. “This is called a thrill and it means that your fistula is not working.” A thrill is a normal finding and means the fistula is functioning properly.

B. "This is not a normal sign; we will call your provider right away.” A lack of thrill is abnormal, not the presence of one.

C. "This is called a bruit and it shows that your fistula is patent." The thrill is felt and the bruit is heard.

D. "This is called a thrill and it means that your fistula is patent." A thrill (vibration) is a normal finding in an AV fistula and indicates adequate blood flow. A bruit (whooshing sound) is heard on auscultation and also confirms patency.

A. Respiratory Alkalosis B. Metabolic Acidosis C. Metabolic Alkalosis D. Respiratory Acidosis

Correct Answer is D

Explanation

A. Respiratory Alkalosis: Alkalosis results from hyperventilation, which is not expected with thoracic trauma.

B. Metabolic Acidosis: Metabolic acidosis occurs due to renal failure, lactic acidosis, or diarrhea, not thoracic trauma.

C. Metabolic Alkalosis: Alkalosis can result from vomiting or excessive bicarbonate intake, not respiratory failure.

D. Respiratory Acidosis: Severe thoracic trauma can impair lung expansion, leading to hypoventilation and CO₂ retention, causing respiratory acidosis.

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The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which intervention should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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