A nurse is reinforcing teaching about monitoring weight with a client who has chronic kidney disease. Which of the following instructions should the nurse include in the teaching?

Use several different scales to obtain the weight.

Weigh at the same time each day.

Calibrate weight scales every week.

Measure weight just prior to voiding.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Using several different scales to obtain the weight is incorrect. Consistency is key when monitoring weight, especially for clients with chronic kidney disease. Using the same scale ensures that weight measurements are accurate and comparable over time. Different scales may have slight variations, leading to inconsistent and unreliable data.
Choice B rationale
Weighing at the same time each day is correct. It is important to weigh at the same time each day, preferably in the morning after voiding and before eating, to obtain consistent and accurate measurements. This helps in monitoring fluid retention and changes in body weight, which are critical for managing chronic kidney disease.
Choice C rationale
Calibrating weight scales every week is not necessary. While it is important to ensure that the scale is accurate, weekly calibration is excessive. Regular calibration according to the manufacturer’s instructions or as needed is sufficient to maintain accuracy. Over-calibration can be time-consuming and may not significantly improve measurement accuracy.
Choice D rationale
Measuring weight just prior to voiding is incorrect. Weighing after voiding provides a more accurate measurement of body weight without the influence of bladder contents. This is especially important for clients with chronic kidney disease, as fluid balance and retention are closely monitored.

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Correct Answer is C

Explanation

Choice A rationale
Kernig’s sign is associated with meningitis, not hypocalcemia. It involves pain and resistance when attempting to extend the leg at the knee while the hip is flexed.
Choice B rationale
Brudzinski’s sign is also associated with meningitis, not hypocalcemia. It involves involuntary lifting of the legs when lifting a patient’s head.
Choice C rationale
Chvostek’s sign is a clinical sign of hypocalcemia. It involves twitching of the facial muscles in response to tapping over the facial nerve.
Choice D rationale
Cullen’s sign is associated with acute pancreatitis and involves bruising around the umbilicus. It is not related to hypocalcemia.

A. Monitor the puncture site for hematoma. B. Elevate the client’s head of bed. C. Insert a urinary catheter. D. Encourage fluid intake. E. Apply a cervical collar to the client.

Correct Answer is ["A","D"]

Explanation

Choice A rationale
Monitoring the puncture site for hematoma is crucial because a hematoma can indicate bleeding at the puncture site, which can lead to complications such as infection or nerve damage. Hematomas can also cause increased intracranial pressure, which can be dangerous for the patient. Therefore, it is essential to monitor the site closely to ensure that any signs of bleeding are detected early and managed appropriately.
Choice B rationale
Elevating the client’s head of bed is incorrect because it can increase the risk of cerebrospinal fluid (CSF) leakage from the puncture site. After a lumbar puncture, it is recommended to keep the patient in a flat position for several hours to reduce the risk of post-lumbar puncture headache and to allow the puncture site to heal properly. Elevating the head of the bed too soon can disrupt this process and lead to complications.
Choice C rationale

Inserting a urinary catheter is incorrect because it is not a standard procedure following a lumbar puncture. The primary focus after a lumbar puncture is to monitor for complications related to the procedure itself, such as bleeding, infection, or CSF leakage. Inserting a urinary catheter is not necessary unless there is a specific indication for it, such as urinary retention or other urological issues.
Choice D rationale
Encouraging fluid intake is correct because it helps to replenish the CSF that was removed during the lumbar puncture. Increased fluid intake can also help to reduce the risk of post- lumbar puncture headache, which is a common complication. Hydration is important for overall recovery and helps to maintain normal bodily functions.
Choice E rationale
Applying a cervical collar to the client is incorrect because it is not related to the care of a lumbar puncture site. A cervical collar is typically used for patients with neck injuries or conditions affecting the cervical spine. It has no role in the management of a lumbar puncture site and would not provide any benefit in this context.

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A nurse is reinforcing teaching about monitoring weight with a client who has chronic kidney disease. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

A nurse is reinforcing teaching about monitoring weight with a client who has chronic kidney disease. Which of the following instructions should the nurse include in the teaching?

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