health assessment in nursing test bank

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In CKD, kidneys struggle to excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac arrhythmias. Hypokalemia (B) is unlikely in CKD due to impaired potassium excretion. Hyperglycemia (C) is more commonly associated with diabetes rather than CKD. Hypercalcemia (D) is not a typical complication of CKD; instead, patients with CKD often experience low calcium levels.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation. This is because early ambulation is crucial in preventing complications such as blood clots and muscle atrophy post hip replacement surgery. It helps improve circulation, prevent joint stiffness, and promote healing. Administering pain medication regularly (A) is important but not the top priority. Providing wound care and dressing changes (C) and monitoring for signs of infection (D) are also important but secondary to early ambulation in preventing complications and promoting recovery.

Correct Answer: C

Rationale: The correct answer is C: Preventing deep vein thrombosis (DVT). It is the most important nursing priority after hip replacement surgery because patients are at high risk for DVT due to immobility and altered blood flow. DVT can lead to serious complications like pulmonary embolism. Monitoring for infection (B) is important but preventing DVT takes precedence. Managing pain (A) is essential but not the top priority. Ensuring proper positioning (D) is important for preventing complications, but DVT prevention is more critical post-hip replacement surgery.

Correct Answer: C

Rationale: The correct answer is C: Jaundice. Patients with chronic liver disease are at risk for developing jaundice due to impaired liver function leading to the accumulation of bilirubin. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates worsening liver function. Incorrect choices: A: Hypoglycemia - Not directly related to chronic liver disease, more commonly seen in diabetes. B: Hyperglycemia - Not typically associated with chronic liver disease unless the patient has underlying diabetes. D: Anemia - Can be a complication of chronic liver disease, but monitoring for jaundice takes priority due to its direct association with liver dysfunction.

Correct Answer: C

Rationale: The correct answer is C: Decreasing intake of trans fats. Trans fats are known to increase LDL cholesterol levels, which are considered "bad" cholesterol. By reducing trans fats in the diet, the patient can lower their cholesterol levels. Saturated fats (choice A) can also increase LDL cholesterol, so increasing intake is not beneficial. Dietary fiber (choice B) helps lower cholesterol by binding to cholesterol in the digestive system, so decreasing intake would not be beneficial. Processed sugars (choice D) do not directly impact cholesterol levels, so increasing intake would not help lower cholesterol. Overall, choosing option C is the most effective dietary change for managing high cholesterol.