Med/Surg Exam 4

Oliguric phase of acute renal failure, how long does it last?

1-3 weeks

A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? A. Place the client on a cardiac monitor immediately. B. Teach the client to limit high-potassium foods. C. Continue to monitor the client's intake and output. D. Ask to have the laboratory redraw the blood specimen.

A

A client has been missing some scheduled hemodialysis sessions. Which intervention is most important for the nurse to implement? A. Discussing with the client his or her acceptance of the disease B. Discussing with the client the option of peritoneal dialysis C. Rescheduling the sessions to another day or another time D. Stressing to the client the importance of going to the sessions

A

A client has end-stage kidney disease (ESKD). The nurse observes tall, peaked T waves on the client's cardiac monitor. Which action by the nurse is best? A. Check the serum potassium level. B. Document the finding in the client's chart. C. Prepare to give sodium bicarbonate. D. Call the health care provider to request an electrocardiogram (ECG).

A

A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best? A. Obtain daily weights of the client. B. Auscultate heart and breath sounds. C. Palpate the client's abdomen. D. Assess the client's diet history.

A

A client with acute kidney injury had normal assessments 1 hour ago. Now the nurse finds that the client's respiration rate is 44 breaths/min and the client is restless. Which assessment does the nurse perform? A. Obtain an oxygen saturation level B. Send blood for a creatinine level. C. Assess the client for dehydration. D. Perform a bedside blood glucose.

A

A client with acute kidney injury is placed on a fluid restriction. To determine whether outcomes related to fluid balance are being met, the nurse assesses for which finding? A. Absence of lung crackles B. Decreased serum creatinine level C. Decreased serum potassium level D. Increased muscle strength

A

A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best? A. "MG is an autoimmune problem in which nerves do not cause muscles to contract." B. "MG is an inherited destruction of peripheral nerve endings and junctions." C. "MG consists of trauma-induced paralysis of specific cranial nerves." D. "MG is a viral infection of the dorsal root of sensory nerve fibers."

A

A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this client's history? A. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" B. "Do you have anyone in your family with renal failure?" C. "Have you had a diet that is low in protein recently? D. "Has a relative had a kidney transplant lately?"

A

A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? A. Discuss what the treatment regimen means to him. B. Refer the client to a mental health nurse practitioner. C. Reschedule the appointments to another date and time. D. Discuss the option of peritoneal dialysis.

A

A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? A. The client has lost 11 pounds in the past 10 days. B. The client's urine specific gravity is 1.048. C. No blood is observed in the client's urine. D. The client's blood pressure is 152/88 mm Hg.

A

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow coma scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

A

The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? A. Inability to perform the six cardinal positions of gaze B. Lateralization to the affected side during the Weber test C. Absent deep tendon reflexes D. Impaired stereognosis

A

The nurse completes which assessment in a client with acute glomerulonephritis and periorbital edema? A. Auscultating breath sounds B. Checking blood glucose levels C. Measuring deep tendon reflexes D. Testing urine for protein

A

When evaluating the effects of a low-protein diet in a client with chronic kidney disease, the nurse is most concerned with which result? A. Albumin level of 2 g/dL B. Calcium level of 8.0 mg/dL C. Potassium level of 5.2 mmol/L D. Magnesium level of 3 mEq/L

A

What is a patient with kidney failure and a low erythropoietin level at risk of developing?

Anemia

What is the priority teaching to a patient who had a recent transsphenoidal procedure to reduce ICP?

Avoid straining, coughing, sneezing, blowing nose

A 23 year old female client was in an automobile accident and is now paraplegic. She is on an intermittent urinary catheterization program and diet as tolerated. The nurse's priority assessment should be to observe for A. Urinary retention B. Bladder distention C. Weight gain D. Bowel evacuation

B

A Glasgow Coma Scale score of 8 or below is an indication of: A. mild head injury B. severe head injury (patient is comatose) C. moderate head injury D. no head injury

B

A client is scheduled to have dialysis in 30 minutes and is due for the following medications: vitamin C, B-complex vitamin, and cimetidine (Tagamet). Which action by the nurse is best? A. Give medications with a small sip of water. B. Hold all medications until after dialysis. C. Give the supplements, but hold the Tagamet. D. Give the Tagamet, but hold the supplements.

B

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? A. "Most people recover after a burn and feel satisfied with their lives." B. "It's true that your life may be different. What concerns you the most?" C. "It is really too early to know how much your life will be changed by the burn." D. "Why do you feel that way? You will be able to adapt as your recovery progresses."

B

The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client's recent history? A. Pyelonephritis B. Myocardial infarction C. Bladder cancer D. Kidney stones

B

The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding? A. Woman with a blood pressure of 158/90 mm Hg B. Client with Kussmaul respirations C. Man with skin itching from head to toe D. Client with halitosis and stomatitis

B

The nurse is providing dietary teaching to a client who was just started on peritoneal dialysis (PD). Which instruction does the nurse provide to this client regarding protein intake? A. "Your protein needs will not change, but you may take more fluids." B. "You will need more protein now because some protein is lost by dialysis." C. "Your protein intake will be adjusted according to your predialysis weight." D. "You no longer need to be on protein restriction."

B

The nurse will explain to the patient who has a T2 spinal cord transection injury that A. use of the shoulders will be limited. B. function of both arms should be retained. C. total loss of respiratory function may occur D. tachycardia is common with this type of injury.

B

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about? A. oral corticosteroids. B. antiparkinsonian drugs. C. magnetic resonance imaging (MRI). D. electroencephalogram (EEG) testing.

B

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A.Insert an indwelling urinary catheter to straight drainage B.Schedule intermittent catheterization every 2 to 4 hours C. Perform a straight catheterization every 8 hours while awake D. Perform Crede's maneuver to the lower abdomen before the client voids

B

The nurse is teaching a client with bladder dys- function from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply. A. Restrict fluids to 1,000 mL/24 hours. B. Drink 400 to 500 mL with each meal. C. Drink fluids midmorning, mid-afternoon, and late afternoon. D. Attempt to void at least every 2 hours. E. Use intermittent catheterization as needed.

B, C, D, E

What vital sign is important to monitor in a patient that recently had a stroke?

BP

What drug is prescribed to patients with Multiple Sclerosis?

Baclofen

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? A. Urine volume B. Creatinine level C. Glomerular filtration rate (GFR) D. Blood urea nitrogen (BUN) level

C

A client has a serum creatinine level of 2.5 mg/dL, a serum potassium level of 6 mmol/L, an arterial pH of 7.32, and a urine output of 250 mL/day. Which phase of acute kidney failure is the client experiencing? A. Intrarenal B. Nonoliguric C. Oliguric D. Postrenal

C

A client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding is present, and the client describes just a "small amount of pain." How does the nurse categorize this injury? A. Partial thickness deep B. Partial thickness superficial C. Full thickness D. Superficial

C

A client has end-stage kidney disease (ESKD). Which food selection by the client demonstrates understanding of a low-sodium, low-potassium diet? A. Bananas B. Ham C. Herbs and spices D. Salt substitutes

C

A client is 24 hours post burn and has the following laboratory results. Which result does the nurse report to the health care provider immediately? A. Arterial pH, 7.32 B. Hematocrit, 52% C. Serum potassium,7.5 mEq/L D. Serum sodium, 131 mEq/L

C

A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? A. Maintaining oxygen saturation of 89% B. Minimal crackles and wheezes in lung sounds C. Maintaining a balanced intake and output D. Limited shortness of breath upon exertion

C

A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time? A. Decreased calcium levels B. Increased phosphorus levels C. No adventitious sounds in the lungs D. Increased edema in the legs

C

A client is taking furosemide (Lasix). To detect a common adverse effect, the nurse obtains which assessment as a priority? A. Breath sounds B. Heart sounds C. Intake and output D. Nutritional patterns

C

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? A. Initiate oxygen via a nasal cannula B. Place the client in a supine position. C. Palpate the bladder for distention. D. Administer a prescribed beta blocker.

C

A nurse is assessing laboratory values for a client who may have acute glomerulonephritis. Which of the following findings should the nurse report to the provider? A. Urine specific gravity of 1.022 B. BUN of 16 mg/dL C. Creatinine clearance of 48 mL/min/m2 D. Potassium level of 4.2 mEq/L

C

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? A. "If you don't want to participate in the rehabilitation program, I'll let the provider know." B. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." C. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." D. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

C

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? Check for A. fecal impaction B. Give the prescribed analgesic. C. Assess the blood pressure (BP) D. Notify the health care provider.

C

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? A. Assess oral temperature. B. Check a potassium level. C. Place on cardiac monitor. D. Assess for pain at contact points.

C

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? A. Palpating the access site for a bruit or thrill B. Using the right arm for a blood pressure reading C. Administering intravenous fluids through the AV fistula D. Checking distal pulses in the left arm in the arm what should they be experiencing

C

After a subtotal parathyroidectomy, if the patient begins to feel numbness and tingling, what is the nursing intervention?

Check Chvostek sign and Trousseau's sign, administer IV calcium gluconate or calcium chloride

A nurse providing discharge teaching for a client who has a new arteriovenous fistula in the right forearm. Which of the following should the nurse include in the teaching as a possible indication of venous insufficiency?

Cold and numb fingers of the right arm

A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? A. Use the catheter for the next laboratory blood draw. B. Monitor the central venous pressure through this line. C. Access the line for the next intravenous medication. D. Place a heparin or heparin/saline dwell after hemodialysis.

D

A client hospitalized for worsening kidney injury suddenly becomes restless and agitated. Assessment reveals tachycardia and crackles bilaterally at the bases of the lungs. Which is the nurse's first intervention? A. Begin ultrafiltration. B. Administer an antianxiety agent. C. Place the client on mechanical ventilation. D. Place the client in high Fowler's position.

D

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse's priority action? A. Calculate the mean arterial pressure (MAP). B. Ask for insertion of a pulmonary artery catheter. C. Take the client's pulse. D. Slow down the normal saline infusion.

D

A client with glomerulonephritis has a glomerular filtration rate (GFR) of 40 mL/min, as measured by a 24-hour creatinine clearance. Which is the nurse's interpretation of this finding? A. Excessive GFR, client at risk for dehydration B. Excessive GFR, client at risk for fluid overload C. Reduced GFR, client at risk for dehydration D. Reduced GFR, client at risk for fluid overload

D

In assessing a client recently diagnosed with acute glomerulonephritis, the nurse asks which question to determine potential contributing factors? A. "Are you sexually active?" B. "Do you have pain or burning on urination?" C. "Has anyone in your family had chronic kidney problems?" D. "Have you had a cold or sore throat within the last 2 weeks?"

D

The RN has assigned a client with a newly placed arteriovenous (AV) fistula in the right arm to an LPN. Which information about the care of this client is most important for the RN to provide to the LPN? A. "Avoid movement of the right extremity." B. "Place gentle pressure over the fistula site after blood draws." C. "Start any IV lines below the site of the fistula." D. "Take blood pressure in the left arm."

D

The nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent respiratory complications in the client? A. Keep an oral airway at the bedside. B. Ensure fluid intake of at least 3 L/day. C. Teach the client pursed-lip breathing techniques. D. Maintain the head of the bed at 30 degrees or greater.

D

What does the acronym FAST stand for?

Face drooping Arm weakness Speech difficulty Time to call 911

What condition is characterized by an increase in T3 and T4 with a normal TSH?

Hyperthyroidism

A patient has a head injury and has IV fluids being administered at a high rate, what is this patient at risk for and what is the priority nursing action?

Increased ICP(fluid overload), titrate the IV fluids

What labs indicate treatment for SIADH has been effective?

Increased Serum Osmolality (280-290) Increased sodium level (135-145) Decreased urine Osmolality Decrease in urine sodium levels

What IV fluid should a burn patient receive in the first 24 hours?

Lactated Ringers

What drug is prescribed to patients with parkinson's disease?

Lovodopa

What DX is associated with AKI?

MI, dehydration, burns, infection, hypotension, allergic reaction

What are some precautions the should be taken while a patient is having a seizure?

Maintain airway, have suction and oxygen ready, protect the head, pad headrails, remove tight clothing if necessary

What is the priority nursing intervention for a patient with Myesthenia Gravis in a Myesthenic crisis?

Maintaining adequate respiratory function

What is a priority discharge teaching for a patient with Parkinson's disease and their family?

No shuffled rugs

After a total thyroidectomy a patient develops stridor, what is the intervention?

Prepare for an emergency tracheostomy and call provider.

What medications are administered to patients with hyperthyroidism?

Propylthiouracil or Methimazole

If a patient had a CVA on the right side, what side would you approach the patient on?

The right side

If a patient is having a partial thyroidectomy and given iodine, what response if best from the nurse?

Verify patient does not have a shellfish allergy prior to administration, follow a high protein and high carb diet prior to surgery, notify provider if patient develops a sore throat, fever, or mouth ulcers, iodine should be administered 10-14 days before procedure

What is the plan of care for an unconscious client with a loss of corneal reflex?

applying lubricating eyedrops

What dietary modifications should be made for someone with hyperthyroidism?

increased calories, proteins, carbs

What are the symptoms of Diabetes Insipidus?

increased urine output, Polydispia, dehydration, hypernatremia, weak pulse, tachycardia, fatigue, nocturia, polyuria, hypotension, low urine specific gravity, poor skin turgor, dry mucous membranes

If a client has hyperparathyroidism, what is the priority intervention?

monitor cardiac function/ Prevent injury

What are some adverse effects of Methimazole

thyrotoxic storm

What is one of the initial signs of Parkinson's disease?

tremors