Adult Health 3 Exam 2
A nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. The client states, "I don't need this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream?
Ammonia
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?
Epinephrine
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values? SATA
Lipase Amylase
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
"Disseminated intravascular coagulation (DIC) is caused by abnormal coagulation involving fibrinogen"
A nurse is teaching a client who has pre-dialysis end-stage kidney disease about diet. Which of the following instructions should the nurse include?
"Reduce intake of foods high in potassium"
A nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. Which of the following information should the nurse include?
"You should anticipate pain the first week during the inflow of dialysate"
A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?
Alchohol use disorder
The nurse understands that continuous renal replacement therapy (CRRT) is indicated for which of the following clients?
A hospitalized client in the intensive care unit (ICU) with an acute kidney injury (AKI)
A nurse is caring for a client who has a new arteriovenous (AV) graft in their left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?
Auscultate the site for a bruit
A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? SATA
Behavior changes Bone pain Pruritus
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Blood Pressure 115/68 mmHg
A client arrives at the emergency department in a state of hypovolemic shock. Fluid replacement is initiated. Which of the following does the clinician expect to increase as the client is treated and begins recovery? SATA
Blood pressure Urine output Renal perfusion
The nurse is caring for a client suspected of having neurogenic shock. Which of the following findings are consistent with neurogenic shock? SATA
Blood pressure 85/54 and heart rate 53 bpm Warm and dry skin and recent spinal cord injury
A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting a nasogastric (NG) tube into the client, which of the following findings should the nurse anticipate?
Coffee-ground drainage
A nurse is caring for a client following their first hemodialysis treatment. The client reports a headache, nausea, and restlessness. The nurse should identify these findings as manifestations of which of the following complications?
Dialysis disequilibrium
A nurse is monitoring a client who has acute kidney injury. Which of the following laboratory findings should the nurse expect? SATA
Elevated BUN HYPERkalemia HYPOcalcemia
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?
Gallstones
A nurse is caring for a client who is to start taking cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can have an adverse interaction with this medication?
Grapefruit Juice
A nurse is reviewing the laboratory test results form a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?
HYPERkalemia
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?
Hematemesis
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
Increase in the heart rate from 88 to 110/min
A nurse is caring for a client who is at risk for shock. Which of the following findings is an early indicator, during compensation, that this complication is developing?
Increased respitatory rate.
A nurse is caring for a client who was admitted for septic shock. The nurse understands the order and stages of shock that the client may go through. Identify which of the following are stages of shock. SATA
Initial Compensatory Refractory/Irreversible Progressive
The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?
Maintain activity restriction to promote rest
Which of the following can prevent complications in the progressive stage of shock? SATA
Monitor laboratory results Support with oxygen administration/supplementation Prepare for mechanical ventilation
A nurse can expect to find which of the following plans for nursing care for a client in a state of disseminated intravascular coagulation (DIC)? SATA
Monitor vital signs Provide neurologic checks Skin assessments to include bony prominences and high pressure sites
The nurse is caring for a client who is in cardiogenic shock. The nurse knows which of the following diagnoses is responsible for causing cardiogenic shock?
Myocardial infarction
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?
Nausea andd Vomiting
A clinician is ordering atropine, an anticholinergic agent, for a client in shock. Which type of shock is suspected?
Neurogenic shock
The nurse is able to identify which of the following are types of distributive shock? SATA
Neurogenic shock Septic shock Anaphylactic shock
The nurse is caring for a client in shock. The nurse understands that which of the following is a vasopressor agent utilized to increase blood pressure by vasoconstriction?
Norepinephrine
A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?
Oliguria
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
Oliguria
A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?
Potassium
A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?
Purulent dialysate outflow.
A client with a severe systemic infection is displaying hypoxemia and elevated lactate levels, along with an altered mental state. Which type of shock is the client most at risk for experiencing?
Septic
A nurse is planning care for a client who is postoperative following a liver transplant and weighs 65 kilograms. Which of the following actions should the nurse plan to take?
Stress the importance of safe food-handling practices
A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?
Sudden abdominal pain
A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?
The client has a 5 lb weight gain since yesterday
A client presents at the emergency department in shock. Blood glucose levels are elevated. Which of the following may explain this development relative to the state of shock?
The client has released the stress hormones cortisol and epinephrine
A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? SATA
Tomatoes Bananas Raisins
In medical management for clients suffering from shock, what are medical management priorities for the clinician and nursing team? SATA
Treat the underlying condition Restore effective cardiac pumping, adequate vasculature, and/or blood volume Initiate medical intervention needs within three hours of presentation
The nurse is caring for a client who is currently in the progressive stage of shock. The nurse knows that which of the following clinical findings indicates the client is now in the irreversible stage of shock? SATA
Unconsciousness Anuria
The nurse is caring for a client diagnosed with shock. During shift report, the nurse reports the results of which assessments that signal signs of the decompensation stage of shock? SATA
Vital signs Skin color Urine output Peripheral pulses
A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?
Withhold oral fluids and food
