NMNC 4510 Concept Synthesis
A 50-year-old client who has aortic stenosis and is scheduled for a valve replacement tells the nurse, "I gave my spouse all my financial records in case I don't make it." Which response by the nurse is best? "Your surgeon is very experienced." "People your age generally do very well." "Are you concerned that you may die during surgery?" "Would you like medication to help you sleep at night?"
"Are you concerned that you may die during surgery?" Rationale: Asking if the client is concerned about dying is reflective and encourages further communication. A statement that the surgeon is experienced may be true, but is not specific to the client's statement and cuts off further communication. Telling the client that other people generally do well is nonspecific and provides false reassurance that is unlikely to decrease anxiety. Asking about whether the client would like sleep medication evades the client's concerns and cuts off more communication about the client's concerns.
When the nurse is obtaining the health history for a client with mitral valve stenosis, which question will be most relevant to ask? "Do you frequently get urinary tract infections?" "Have you had a recent episode of pneumonia?" "Did you ever have strep throat during childhood?" "Do you have a family history of heart attack or angina?"
"Did you ever have strep throat during childhood?" Rationale: Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve.
A client who has chronic kidney failure is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the client indicates understanding of the therapy? 1. "It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration." 2. "It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine." 3. "It decreases the need for immobility because it clears toxins in short and intermittent periods." 4. "It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."
"It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion." Rationale: Diffusion moves particles from an area of greater concentration to an area of lesser concentration; osmosis moves fluid from an area of lesser to an area of greater concentration of particles, thereby removing waste products into the dialysate, which is then drained from the abdomen. The principle of ultrafiltration involves a pressure gradient, which is associated with hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses the peritoneal membrane to indirectly cleanse the blood. Dialysate does not clear toxins in a short time; exchanges may occur four or five times a day.
A client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client reports feeling depressed and irritable. The client's spouse asks the nurse about the anticipated plan of care. Which response would the nurse provide? 1. "The staff will provide total care, because the infection causes severe fatigue." 2. "Mood elevators will be prescribed to improve the depression and irritability." 3. "Vitamin B12 will be prescribed for the anemia, and the stools will be dark." 4. "Protein foods will be restricted so the kidneys can clear the waste products."
"Protein foods will be restricted so the kidneys can clear the waste products." Rationale: One of the kidney's functions is to excrete nitrogenous waste from protein metabolism; restriction of protein intake decreases the workload of the damaged kidneys. The client is encouraged to be as active and independent as possible. Medications are avoided because they may mask symptoms. Iron and folic acid supplements are used for anemia in chronic kidney disease; Vitamin B12 is used for pernicious anemia and does not make the stools dark; iron makes the stools dark.
Which information would the nurse include in response to a client's questioning a protein-restricted dietary change required for his or her acute kidney injury? 1. "A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses." 2. "Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis." 3. "This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys." 4. "Currently, your body is unable to synthesize amino acids, so the nitrogen for amino acid synthesis must come from the dietary protein."
"This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys." Rationale: The amount of protein permitted in the diet depends on the extent of kidney function; excess protein causes an increase in urea concentration, excess metabolic waste, and added stress on the kidneys. The restricted protein diet prevents overburdening the client's kidneys at this time. When experiencing acute kidney injury, the kidneys are unable to eliminate the waste products of a high-protein diet. The body is able to synthesize the nonessential amino acids. Urea is a waste product of protein metabolism; the body is able to synthesize the nonessential amino acids.
An arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client is most likely to exhibit these blood gas results? 1) A client with pulmonary fibrosis 2) A client with uncontrolled type 1 diabetes 3) A client who has been vomiting for 3 days 4) A client who takes sodium bicarbonate for indigestion
1) A client with pulmonary fibrosis
A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? 1) Encouraging a fluid intake of 3 L daily 2) Suctioning via the tracheostomy every hour 3) Applying an occlusive dressing over the surgical site 4) Using cotton balls to cleanse the stoma with peroxide
1) Encouraging a fluid intake of 3 L daily
When the nurse obtains vital signs of blood pressure 90/60 mm Hg, pulse 96 beats/minute, and respiratory rate 10 breaths/minute for a postoperative client who is receiving hydromorphone by a patient-controlled analgesia (PCA) pump, which nursing action would be the priority? 1) Give naloxone intravenously per protocol. 2) Assess the client's pain level on a 10-point scale. 3) Document the vital signs in the client record. 4) Notify the hospital rapid response team.
1) Give naloxone intravenously per protocol.
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance would the nurse identify based on these results? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis
1) Metabolic acidosis
Which statement made by a student nurse indicates the need for further learning about assessing for respiratory system manifestations of alkalosis? Select all that apply. One, some, or all responses may be correct. 1) "I should assess for an increased rate of ventilation in respiratory alkalosis." 2) "I should assess for a decreased depth of ventilation in respiratory alkalosis." 3) "I should assess for a decreased rate of ventilation in respiratory alkalosis." 4) "I should assess for an increased depth of ventilation in respiratory alkalosis." 5) "I should assess for a decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis.
2) "I should assess for a decreased depth of ventilation in respiratory alkalosis." 3) "I should assess for a decreased rate of ventilation in respiratory alkalosis."
A client develops acute respiratory distress syndrome (ARDS). The nurse assesses the client and notes signs of pulmonary edema and atelectasis. The findings correspond to which phase of ARDS? 1) Fibrotic 2) Exudative 3) Reparative 4) Proliferative
2) Exudative
A client with a 10-year history of emphysema is hospitalized for acute respiratory distress. Which assessment finding would the nurse expect to identify? 1) Chest pain on inspiration 2) Prolonged expiration with use of accessory muscles 3) Signs and symptoms of respiratory alkalosis 4) Decreased respiratory rate
2) Prolonged expiration with use of accessory muscles
A client is extubated in the postanesthesia care unit after surgery. For which common response would the nurse be alert when monitoring the client for acute respiratory distress? 1) Bradycardia 2) Restlessness 3) Constricted pupils 4) Clubbing of the fingers
2) Restlessness
The charge nurse is communicating with the registered nurse about caring for a client with a respiratory disorder. Which instructions can be delegated to the registered nurse to provide effective care to the client? Select all that apply. One, some, or all responses may be correct. 1) "Feed the client three times a day." 2) "Change the client's clothes every 6 hours." 3) "Assess the client's respirations after 1 hour." 4) "Provide intravenous medication every 3 hours." 5) "Inform the licensed practical nurse if the respiration rate changes."
3) "Assess the client's respirations after 1 hour." 4) "Provide intravenous medication every 3 hours."
A client is admitted to an intensive care unit with a diagnosis of acute respiratory distress syndrome (ARDS). The nurse expects which assessment finding? 1) Hypertension 2) Tenacious sputum 3) Altered mental status 4) Slow rate of breathing
3) Altered mental status
The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which is appropriate to include? 1) They are indicative of pleural rubbing. 2) They are signs of bronchial constriction. 3) Crackles are located in the smaller air passages. 4) Crackles are heard during respiratory expiration.
3) Crackles are located in the smaller air passages.
The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? 1) Respiratory alkalosis 2) Poor oxygen perfusion 3) Normal acid-base balance 4) Compensated metabolic acidosis
3) Normal acid-base balance
The nurse determined a client's arterial blood gases reflected a compensated respiratory acidosis. The pH was 7.34; which additional laboratory value did the nurse consider? 1) The partial pressure of oxygen (PO2) value is 80 mm Hg. 2) The partial pressure of carbon dioxide (PCO2) value is 60 mm Hg. 3) The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L). 4) Serum potassium value is 4 mEq/L (4 mmol/L).
3) The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L).
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute pneumonia. The client is in moderate respiratory distress. The nurse would place the client in which position to enhance comfort? 1) Side-lying with head elevated 45 degrees 2) Sims with head elevated 90 degrees 3) Semi-Fowler with legs elevated 4) High Fowler using the bedside table to rest the arms
4) High Fowler using the bedside table to rest the arms
Which medical intervention would the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 1) Chest tube insertion 2) Aggressive diuretic therapy 3) Administration of beta-blockers 4) Positive end-expiratory pressure (PEEP)
4) Positive end-expiratory pressure (PEEP)
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1) Administer sedatives as frequently as possible. 2) Turn the client every 4 hours. 3) Increase ventilator settings every 2 hours. 4) Suction as needed.
4) Suction as needed.
A client is experiencing severe acute respiratory distress. Which response would the nurse expect the client to exhibit? 1) Tremors 2) Anasarca 3) Bradypnea 4) Tachycardia
4) Tachycardia
The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO2 80 mm Hg (10.64 kPa), PaCO2 55 mm Hg (7.32 kPa), and HCO3 23 mEq/L (23 mmol/L). How would the nurse interpret these findings? 1) Hypoxemia 2) Hypocapnia 3) Compensated metabolic acidosis 4) Uncompensated respiratory acidosis
4) Uncompensated respiratory acidosis
Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). Which action would the nurse take to reduce the possibility of retinopathy of prematurity? 1) Humidifying oxygen flow to prevent dehydration 2) Uncovering the entire body to increase exposure to the oxygen 3) Applying eye patches to both eyes to protect them from the oxygen 4) Verifying oxygen saturation frequently to adjust flow on the basis of need
4) Verifying oxygen saturation frequently to adjust flow on the basis of need
Which hormone influences kidney function? 1. Renin 2. Bradykinin 3. Aldosterone 4. Erythropoietin
Aldosterone Rationale: Released from the adrenal cortex, aldosterone influences kidney function. Renin, bradykinin, and erythropoietin are kidney hormones.
For which complications would the nurse monitor a client hospitalized with end-stage kidney disease? Select all that apply. One, some, or all responses may be correct. 1. Anemia 2. Dyspnea 3. Jaundice 4. Hyperexcitability 5. Hypophosphatemia
Anemia, Dyspnea Rationale: Anemia results from decreased production of erythropoietin by the kidneys, which causes decreased erythropoiesis by bone marrow. Dyspnea is a result of fluid overload, which is associated with chronic kidney failure. Jaundice occurs with biliary obstruction or liver disorders, not with kidney failure. Hyperphosphatemia occurs with kidney failure, not hypophosphatemia. Hyperexcitability is not a feature of end-stage kidney disease.
When caring for an older client who has had multiple recent hospital admissions for heart failure, which action would the nurse take first? Ask the client about medication use and activity level at home. Suggest discharge to a local assisted living setting with the client. Teach the client about the importance of limiting home salt intake. Talk with the client about having home health visits after discharge.
Ask the client about medication use and activity level at home. Rationale: Further assessment of the client's home situation and possible reasons for frequent readmissions are needed before other actions can be taken.
After donning gloves, which action would the nurse take first after discovering a large amount of blood under the buttocks of a client who had a cardiac catheterization through the femoral artery? Apply pressure to the site. Obtain vital signs. Change the client's gown and bed linens. Assess the catheterization site.
Assess the catheterization site. Rationale: Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined, the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs. Changing the client's gown and bed linens is not necessary until the bleeding is controlled and the client is stabilized.
Which nursing intervention is specific to clients in active labor who present with a history of cardiac disease? Encouraging frequent voiding Checking the blood pressure hourly Auscultating the lungs for crackles every 30 minutes Helping turn the client from side to side at 15-minute intervals
Auscultating the lungs for crackles every 30 minutes Rationale: Clients with cardiac problems are prone to heart failure during active labor; crackles indicate the presence of pulmonary edema. Encouraging frequent voiding and checking the blood pressure hourly is done for all clients who are in labor. Helping turn the client from side to side at 15-minute intervals is not necessary; although clients who are in labor are maintained on the side to facilitate venous return, the sides do not have to be alternated every 15 minutes.
Which catecholamine receptor is responsible for increased heart rate? Beta-1 receptor Beta-2 receptor Alpha-1 receptor Alpha-2 receptor
Beta-1 Receptor Rationale: Beta-1 receptors are responsible for increased heart rate. Beta-2 receptors, alpha-1 receptors, and alpha-2 receptors are not present in the heart; therefore, they are not responsible for increasing the heart rate. Beta receptors are present in such organs as blood vessels, kidneys, bronchioles, and bladder. Alpha receptors are present in such organs as eyes, skin, and liver.
Which medication prescribed for a client with an acute episode of heart failure would the nurse question? Diuretic Beta blocker Long-acting nitrate Angiotensin receptor blocker
Beta-blocker Rationale: Beta blockers reduce cardiac output and are contraindicated for clients with acute heart failure, although they are frequently used to prevent progression of chronic heart failure. Diuretics are used in acute heart failure to decrease hypervolemia and congestion. Long-acting nitrates are used in heart failure to reduce preload. Angiotensin receptor blockers are used in heart failure to decrease fluid overload and afterload.
A client with acute kidney injury states, "Why am I experiencing twitching and tingling of my fingers and toes?" Which process would the nurse consider when formulating a response to this client? 1. Acidosis 2. Calcium depletion 3. Potassium retention 4. Sodium chloride depletion
Calcium depletion Rationale: In kidney failure, as the glomerular filtration rate decreases, phosphorus is retained. As hyperphosphatemia occurs, calcium is excreted. Calcium depletion hypocalcemia causes tetany, which causes twitching and tingling of the extremities, among other symptoms. Acidosis, potassium retention, and sodium chloride depletion are not characterized by twitching and tingling of the extremities.
The nurse is assessing four different clients. Which findings show that the client is at risk for heart disease? Client 1: Red color assessed. Location assessed- face, area of trauma, sacrum, shoulders Client 2: Bluish color assessed. Location assessed- nail beds, lips, mouth, skin. Client 3: Pallor color assessed. Location assessed- Face, conjunctiva, nail beds, palms of hands. Client 4: Yellow orange color assessed. Location assessed- sclera, mucous membranes, skin.
Client 2 Rationale: Client 2 is at risk for heart disease because the nail beds, lips, mouth, and skin show cyanosis, or a bluish color. This may be due to an increased amount of deoxygenated hemoglobin, which may be due to heart or lung disease.
The nurse reviews the kidney function blood studies of four clients. Which client's results indicate kidney impairment? Client 1: Serum Creatinine 0.1 mg/dL; BUN 16 mg/dL Client 2: Serum Creatinine 0.8 mg/dL; BUN 18 mg/dL Client 3: Serum Creatinine 1.2 mg/dL; BUN 20 mg/dL Client 4: Serum Creatinine 1.9; BUN 22 mg/dL
Client 4 Rationale: Elevated creatinine level signifies impaired kidney function or kidney disease. As the kidneys become impaired for any reason, the creatinine level in the blood will rise due to poor clearance of creatinine by the kidneys. Abnormally high levels of creatinine thus warn of possible malfunction or failure of the kidneys. If the kidneys are not able to remove urea from the blood normally, the blood urea nitrogen (BUN) level rises. The normal range of serum creatinine lies between 0.6 and 1.2 mg/dL (53.04-106.08 mmol/L). The normal range of BUN lies between 10 and 20 mg/dL (3.57-7.14 mmol/L). Client 4's levels indicate kidney impairment. The serum creatinine and BUN are within normal limits for clients 1, 2, and 3.
When caring for a client with heart failure, which type of lung sounds would the nurse expect to hear? Stridor Crackles Wheezes Rhonchi
Crackles Rationale: Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal constriction or obstruction. Wheezes are typically heard with airway narrowing caused by asthma. Rhonchi are heard when airways are obstructed with thick secretions caused by problems such as pneumonia.
A client develops a transfusion reaction. Which clinical response will the nurse assess to determine kidney damage? 1. Glycosuria 2. Blood in the urine 3. Decreased urinary output 4. Acute pain over the kidney
Decreased urinary output Rationale: Diminished renal function usually is evidenced by a decrease in urine output to less than 100 to 400 mL/24 h. Glycosuria is unrelated to a transfusion reaction. Although blood in the urine and acute pain over the kidney are related to the renal system and are signs of an acute hemolytic reaction, their presence does not necessarily indicate that kidney damage has occurred.
A client with acute kidney injury is moved into the diuretic phase after 1 week of therapy. During this phase, which clinical indicators would the nurse assess? Select all that apply. One, some, or all responses may be correct. 1. Skin rash 2. Dehydration 3. Hypovolemia 4. Hyperkalemia 5. Metabolic acidosis
Dehydration, Hypovolemia Rationale: In the diuretic phase, excretion of fluids retained during the oliguric phase occurs and may reach 3 to 5 L daily; unless fluid replacement occurs, dehydration and hypovolemia is a potential. Skin rash is not associated with the diuretic phase. Hyperkalemia develops in the oliguric phase when glomerular filtration is inadequate. Metabolic acidosis occurs in the oliguric, not diuretic, phase.
A child being treated with cardiac medications developed vomiting, bradycardia, anorexia, and dysrhythmias. The nurse understands which medication toxicity is responsible for these symptoms? Digoxin Nesiritide Dobutamine Spironolactone
Digoxin Rationale: Digoxin helps improve pumping efficacy of the heart, but an overdose can cause toxicity leading to nausea, vomiting, bradycardia, anorexia, and dysrhythmias.
A client with a history of chronic kidney disease is hospitalized. Which assessment findings would alert the nurse to suspect kidney insufficiency? 1. Facial flushing 2. Edema and pruritus 3. Dribbling after voiding 4. Diminished force of urination
Edema and pruritus Rationale: The accumulation of metabolic wastes in the blood (uremia) can cause pruritus; edema results from fluid overload caused by impaired urine production. Pallor, not flushing, occurs with chronic kidney disease as a result of anemia. Dribbling after voiding is a urinary pattern that is not caused by chronic kidney disease; this may occur with prostate problems. Diminished force and caliber of stream occur with an enlarged prostate, not kidney disease.
Which organ-specific autoimmune disorder would the nurse associate with a client's kidney? 1. Graves disease 2. Addison disease 3. Goodpasture syndrome 4. Guillain-Barré syndrome
Goodpasture syndrome Rationale: Goodpasture syndrome is an autoimmune disorder associated with the client's kidney. Graves disease and Addison disease are autoimmune disorders associated with the endocrine system. Guillain-Barré syndrome is an autoimmune disorder associated with the central nervous system.
Which complication is the most serious for a client with kidney failure? 1. Anemia 2. Weight loss 3. Uremic frost 4. Hyperkalemia
Hyperkalemia Rationale: Decreased glomerular filtration leads to hyperkalemia, which may cause lethal dysrhythmias such as cardiac arrest. Anemia may occur but is not the most serious complication and should be treated in relation to the client's clinical manifestation; erythropoietin and iron supplements usually are used. Weight loss alone is not life threatening. Uremic frost, a layer of urea crystals on the skin, causes itching, but it is not the most serious complication.
The primary health care provider for a client with chronic kidney disease prescribed immediate hemodialysis for the first time. Which clinical manifestation indicates the need for immediate hemodialysis in this client? 1. Ascites 2. Acidosis 3. Hypertension 4. Hyperkalemia
Hyperkalemia Rationale: Protein breakdown liberates cellular potassium ions, leading to hyperkalemia, which can cause a cardiac dysrhythmia and standstill. The failure of the kidneys to maintain a balance of potassium is one of the main indications for dialysis.
During the oliguric phase of acute kidney injury, for which abnormal finding would the nurse monitor in the client? 1. Hypothermia 2. Hyperphosphatemia 3. Hypocalcemia 4. Hypernatremia
Hyperphosphatemia Rationale: The kidneys retain potassium during the oliguric phase of acute kidney injury; an elevated potassium level is one of the main indicators for placing a client on hemodialysis when he or she is experiencing acute kidney injury. Hypothermia does not occur with acute kidney injury. Serum levels of phosphorus decrease during the oliguric phase of kidney failure. The retained fluids create a hemodilution effect and hyponatremia occurs, not hypernatremia.
Cardiac catheterization in a child with a ventricular septal defect (VSD) serves which purpose? Identifies the specific location of the defect Confirms the presence of a pansystolic murmur Reveals the degree of cardiomegaly that is present Establishes the presence of ventricular hypertrophy
Identifies the specific location of the defect Rationale: Cardiac catheterization visualizes the exact location of the ventricular septal defect; also, it measures pulmonary pressures. A murmur can be heard with a stethoscope placed at the left lower sternal border. Cardiomegaly and ventricular hypertrophy are both demonstrated on electrocardiography and echocardiography.
Which statement explains why metabolic acidosis develops with kidney failure? 1. Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2. Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 3. Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4. Impaired glomerular filtration, causing retention of sodium and metabolic waste products
Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Rationale: Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis results. The rate of respirations increases in metabolic acidosis to compensate for a low pH. The fluid balance does not significantly alter the pH. The retention of sodium ions is related to fluid retention and edema rather than to acidosis.
Which would the nurse consider the major characteristic of a cardiac malformation associated with left-to-right shunting? Increased hematocrit Severe growth delay Clubbing of the fingers and toes Increased blood flow to the lungs
Increased blood flow to the lungs Rationale: With a left-to-right shunt, blood flows through a defect in the ventricular wall of the heart and is shunted from the higher pressure left side to the lower pressure right side. The increased blood flow from the right ventricle results in an increased blood flow to the lungs. Polycythemia and an increased hematocrit are not common in children with a left-to-right shunt. Severe growth delay is not common in children with a left-to-right shunt. Clubbing is a more common finding in children with a right-to-left shunt.
A client is admitted to the hospital in the oliguric phase of acute kidney injury. The client's urine output for the past 12 hours was 200 mL. The nurse notes a prescription for 900 mL of oral fluids over the next 24 hours. Which interpretation of the amount of prescribed fluid would the nurse make? 1. It equals the expected urinary output for the next 24 hours. 2. It will prevent the development of pneumonia and a high fever. 3. It will compensate for both insensible and expected output over the next 24 hours. 4. It will reduce hyperkalemia, which can lead to life-threatening cardiac dysrhythmias.
It will compensate for both insensible and expected output over the next 24 hours. Rationale: Insensible losses are 500 mL to 1000 mL in 24 hours, with an average of about 600 mL; the measured output is about 400 mL in 24 hours based on the available history (about 200 mL in 12 hours). Based on the history, the expected urinary output should be about 400 mL in the next 24 hours, far less than 900 mL. More than 900 mL daily is necessary to help prevent pneumonia and its associated fever. Hyperkalemia in acute kidney injury is caused by inadequate glomerular filtration and is not related to fluid intake.
Which landmark is correct for the nurse to use when auscultating the mitral valve? Left fifth intercostal space, midaxillary line Left fifth intercostal space, midclavicular line Left second intercostal space, sternal border Left fifth intercostal space, sternal border
Left fifth intercostal space, midclavicular line
The nurse is preparing to assess the heart of a client during a routine health checkup. Which positioning of the client would be appropriate to assess the murmurs of the heart? supine dorsal recumbent left lateral recumbent sims
Left lateral recumbent position Rationale: The client should lie in the lateral recumbent position so that the nurse can effectively detect heart murmurs (as shown in Figure 2). The supine position provides easy access to the pulse sites (shown in Figure 1). The client should be placed in the dorsal recumbent position (Figure 3) for abdominal assessment. Sims position (Figure 4) is used so that the nurse can assess the rectum and vagina.
The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis report. Which urinary finding indicates the need to notify the primary health care provider? 1. Acidic pH 2. Glucose negative 3. Bacteria negative 4. Presence of large proteins
Presence of large proteins Rationale: The glomeruli are not permeable to large proteins such as albumin or red blood cells, and finding them in the urine is abnormal; the nurse would report their presence to the primary health care provider to modify the client's treatment plan.
Which process is a function of the kidney hormones? 1. Prostaglandin increases blood flow and vascular permeability. 2. Bradykinin regulates intrarenal blood flow via vasodilation or vasoconstriction. 3. Renin raises blood pressure because of angiotensin and aldosterone secretion. 4. Erythropoietin promotes calcium absorption in the gastrointestinal tract tract.
Renin raises blood pressure because of angiotensin and aldosterone secretion. Rationale: Renin is a kidney hormone that raises blood pressure as a result of angiotensin and aldosterone secretion. Prostaglandin is a kidney hormone that regulates intrarenal blood flow via vasodilation or vasoconstriction. Bradykinin is a kidney hormone that increases blood flow and vascular permeability. Erythropoietin is a kidney hormone that stimulates the bone marrow to make red blood cells.
The nurse teaches a client with chronic kidney disease to avoid all salt substitutes in his or her diet. Which rationale supports the nurse's instruction? 1. A person's body tends to retain fluid when a salt substitute is included in the diet. 2. Limiting salt substitutes in the diet prevents a buildup of waste products in the blood. 3. Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats. 4. The salt substitute substances interfere with capillary membrane transfer, resulting in anasarca.
Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats. Rationale: Salt substitutes usually contain potassium, which can lead to hyperkalemia; dysrhythmias are associated with hyperkalemia. Chronic kidney disease already places the client at a higher risk for hyperkalemia because of poor elimination of fluids and electrolytes. Sodium, not salt substitutes, in the diet causes retention of fluid. Salt substitutes do not contain substances that influence blood urea nitrogen and creatinine levels; these are the result of protein metabolism. There is not a substance in the salt substitute that interferes with capillary membrane transfer. Anasarca is extensive fluid in the tissues throughout the body and more extensive than typical edema.
Which nursing intervention is the priority when the nurse notices that the client has a blood pressure of 90/70 mm Hg and a heart rate of 50 beats per minute while the nurse is performing nasotracheal suctioning? Administer intravenous fluids to the client. Report to the primary health care provider. Stop the suctioning procedure immediately. Administer 100% oxygen manually to the client.
Stop the suctioning procedure immediately. Rationale: Nasotracheal suctioning can result in vagal stimulation and bronchospasm. Vagal stimulation can result in hypotension, bradycardia, heart block, ventricular tachycardia, or other dysrhythmias and require immediate intervention. A blood pressure of 90/70 mm Hg and heart rate of 50 breaths per minute indicate hypotension and bradycardia so the nurse would immediately stop the suctioning procedure. The nurse can report to the primary health care provider, but only after stopping the suctioning. The nurse can administer intravenous fluids to the client, but only after ensuring the safety of the client. The nurse can administer 100% oxygen to the client, but only after stopping suctioning.
Which topics will the nurse include in discharge teaching for a client who has had a mitral valve replacement with a mechanical valve? SATA Need for daily aspirin Symptoms of infection Use of pain medications Wound care for leg incision Purpose of anticoagulant medications
Symptoms of infection Use of pain medications Purpose of anticoagulant medications
A child is returned to the pediatric intensive care unit after cardiac surgery. The child has a left chest tube attached to water-seal drainage, an intravenous line running of D5 ½ NS at 4 mL/h, and a double-lumen nasogastric tube connected to continuous suction. A cardiac monitor is in place, as is a dressing on the left side of the chest dressing. Which is the priority nursing intervention? Auscultating breath sounds Testing the level of consciousness Measuring drainage from both tubes Determining the suction pressure of the nasogastric tube
Testing the level of consciousness Rationale: Assessing the level of consciousness provides the nurse with information about how awake the client is and therefore how able to clear the throat and protect the airway. The airway takes priority over listening to the lungs (checking for breathing: ABCs—airway-breathing-circulation), measuring drainage, or determining the suction pressure of the nasogastric tube.
A client is diagnosed with acute kidney failure secondary to dehydration. An intravenous (IV) infusion of 50% glucose with regular insulin is prescribed to address which purpose? 1. To correct hyperkalemia 2. To increase urinary output 3. To prevent respiratory acidosis 4. To increase serum calcium levels
To correct hyperkalemia Rationale: The 50% glucose and regular insulin infusion treats the hyperkalemia associated with kidney failure; it moves potassium from the intravascular compartment into the intracellular compartment. Insulin will not increase urinary output. Insulin is not a treatment for respiratory acidosis. Insulin and glucose do not increase serum calcium levels.
Which activity would the nurse teach clients to avoid after having implantation of a permanent cardiac pacemaker? Having a computed tomography (CT) scan Standing near a microwave Swimming in saltwater Touring a power plant
Touring a power plant Rationale: Large electrical fields can change pacemaker settings and should be avoided. These clients should avoid magnetic resonance imaging (MRI), not a CT scan. Modern microwaves are shielded and do not cause pacemaker problems. Water, regardless of whether it is fresh or saltwater, will not affect a pacemaker.
For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? SATA Weight loss Unusual fatigue Dependent edema Nocturnal dyspnea
Unusual fatigue Dependent edema Nocturnal dyspnea Rationale: Unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure.
When assessing a client who has aortic stenosis and is scheduled for aortic valve replacement, which finding by the nurse is most important to communicate to the health care provider? Loud systolic murmur Multiple dental caries Heartburn when lying down Paroxysmal nocturnal dyspnea
multiple dental caries Rationale: Multiple dental caries increase the risk for endocarditis in clients with valvular disease and caries should be treated before surgery. A loud systolic murmur is typical for aortic stenosis. Heartburn will be treated with medications such as histamine blockers or protein pump inhibitors, but is not a reason to postpone surgery. Paroxysmal nocturnal dyspnea is a common symptom of severe aortic stenosis.
