Exam 3 Sole Ch. 14-16 IGGY Ch. 32, 44-45, 68
Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective?
"I will measure my urinary output each day to help calculate the amount I can drink."
Which statement by the nurse when explaining the purpose of positive end expiratory pressure (PEEP) to the family members of a patient with ARDS is accurate?
"PEEP prevents the lung air sacs from collapsing during exhalation."
After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?
A patient with septicemia who has intercostal and suprasternal retractions
To evaluate the effectiveness of ordered interventions for a patient with ventilator failure, which diagnostic test will be most useful to the nurse?
Arterial blood gas analysis
When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first?
Assess oxygenation using pulse oximetry.
The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is a priority for the nurse to take?
Assist the patient with staged coughing.
When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula?
Auscultate for a bruit at the fistula site.
Which information will be included when the nurse is teaching self-management to a patient who is 1:24 PM receiving peritoneal dialysis (Select all that apply)?
Avoid commercial salt substitutes. Take phosphate-binders with each meal. Choose high-protein foods for most meals.
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the
Bowel sounds.
A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician?
Check blood pressure before starting dialysis.
During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first?
Check patient's blood pressure (BP).
The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider?
Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.
The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms?
Decreasing PaO2 levels despite increased FiO2 administration
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?
Elevate head of bed to 30 to 45 degrees.
A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
Endotracheal intubation and positive pressure ventilation
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patients plan of care?
Frequent neurological assessments
A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following medications ordered. Which medication should the nurse discuss with the health care provider before giving?
Gentamicin (Garamycin) 60 mg IV
A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?
Glomerular filtration rate (GFR)
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next?
Increase the oxygen flow rate.
A patient complains of leg cramps during hemodialysis. The nurse should first
Infuse a bolus of normal saline.
Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit?
Insert an indwelling urinary catheter.
A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?
Insert urethral catheter.
A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with
Insertion of a pulmonary artery catheter.
Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation?
Knee and hip joint pain
The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required?
Magnesium hydroxide
The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be
Maintaining cardiac output
The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action?
Monitor the patient's airway patency.
A patient presents to the emergency department in acute respiratory failure secondary to community acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?
Noninvasive positive-pressure ventilation (NPPV)
A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action is a priority for the nurse to include in the plan of care?
Offer the patient fluids at frequent intervals.
A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange?
On the left side
After receiving change-of-shift report, which patient should the nurse assess first?
Patient who has just returned from having hemodialysis and has a heart rate of 124/min
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patients left naris. What is the best nursing action?
Place a nasal drip pad under the nose
A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first?
Place the patient on a cardiac monitor.
Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful?
Poached eggs, whole-wheat toast, and apple juice
Which actions should the nurse initiate to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)?
Provide a "sedation holiday" daily. Elevate the head of the bed to at least 30°. Give prescribed pantoprazole (Protonix). Provide oral care with chlorhexidine (0.12%) solution daily. (oral care q2)
The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?
Red-brown drainage from orogastric tube
While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102 F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)?
Reduce ambient room temperature and administer antipyretics.
In assessing a patient, the nurse understands that an early sign of hypoxemia is:
Restlessness
A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's
Serum creatinine
A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention?
The LPN/LVN administers the iron supplement and phosphate binder with lunch.
Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?
The patient cleans the catheter while taking a bath each day.
Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation?
The patient has metastatic lung cancer.
The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse?
The patient is exhibiting purposeful movement
The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?
The patient's PaO2 is 45 mm Hg.
A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, which information obtained by the nurse indicates that the positioning is effective?
The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%.
A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider?
The patient's peritoneal effluent appears cloudy.
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider?
The patient's pulse oximetry indicates an O2 saturation of 91%.
A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?
Urine output over an 8-hour period is 2500 mL.
During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?
Use pulse oximetry to check the oxygen saturation.
Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient's
potassium.
