test 2

A client with acute kidney failure is complaining of a metallic taste in the mouth and has no appetite. Based on this data, which intervention by the nurse is the most appropriate? A) Provide mouth care before meals. B) Administer an antiemetic as prescribed. C) Restrict fluids. D) Encourage the intake of protein, salt, and potassium.

A) A metallic taste in the mouth is due to uremia. The nurse should provide mouth care before meals to reduce this taste sensation and improve the client's oral intake. An antiemetic would be prescribed for nausea. Restricting fluids would not reduce the metallic taste in the mouth. Encouraging intake of protein, salt, and potassium would exacerbate the uremia that is causing the metallic taste in the mouth.

What drug may be used to treat nausea and vomiting associated with operative procedures? A) Metoclopramide B) Acetaminophen C) Midazolam D) Fentanyl

A) An antiemetic such as metoclopramide may be used to treat nausea and vomiting associated with operative procedures. A nonopioid analgesic such as acetaminophen provides temporary analgesia for mild to moderate pain. An anxiolytic such as midazolam is a relaxant. An opioid analgesic such as fentanyl controls moderate to severe pain but does not alter the pain threshold.

The nurse is providing care to a client with arterial blood gas analysis as follows: PaO2 of 82, PaCO2 of 49, HCO3 of 26, and pH of 7.31. Which assessment by the nurse is correct? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Metabolic acidosis

A) Both the pH and the carbon dioxide levels represent acidosis. The PaO2 of 82 is on the low end of normal and the bicarbonate level is normal, indicating that this is respiratory acidosis rather than metabolic acidosis.

A client diagnosed with acute kidney injury (AKI) will be discharged to home in the next few days. When conducting dietary instruction, the nurse should teach the client to choose proteins that are high in biological value. Which client statement indicates that this teaching has been effective? A) "I will be sure to include eggs in my diet." B) "I should include vegetables at every meal." C) "Legumes should be included in my diet, because they are complete proteins." D) "I will eat nuts daily because they are high in protein."

A) Eggs are an excellent source of essential amino acids and are recommended as part of the diet for a client with acute kidney injury (AKI) who is on a protein-restricted diet. Legumes, nuts, and vegetables do contain protein, but they are incomplete proteins and thus not as good a protein source as eggs.

A client presents with decreased blood volume, hypotension, tachycardia, and tachypnea during surgery. Which of the following intraoperative complications is most likely? A) Hypovolemia B) Hypervolemia C) Hypokalemia D) Hypernatremia

A) Hypovolemia is an intraoperative complication that presents with decreased fluid (blood) volume, decreased blood pressure, decreased urine output, increased heart rate, and increased respiratory rate. This client is presenting with decreased blood volume, low blood pressure, and fast heart and respiratory rates, and so is probably hypovolemic. Hypervolemia would present with increased fluid volume and blood pressure. This client is not presenting with any of the signs of hypokalemia or hypernatremia.

The nurse educator in a gastrostomy clinic is teaching a group of clients about factors that play a role in the formation of gallstones. Which client would the nurse identify as having the highest risk for gallstone formation due to genetic factors?" A) A Native American client B) An African American client C) An Asian client D) A Norwegian client

A) Native Americans have a higher incidence of gallstones than Asians, Caucasians, and African Americans. This higher incidence is thought to result from a genetic predisposition to secrete high levels of cholesterol in the bile.

The nurse working on a pediatric unit is caring for a client newly diagnosed with asthma. Which assessment data indicate impending respiratory failure and the need for immediate intervention? Select all that apply. A) Shallow respirations B) Slightly diminished breath sounds C) Decreased wheezing D) Increased crackles E) Increased respiratory rate

A) Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow respirations with significantly diminished breath sounds and decreased wheezing may indicate exhaustion and impending respiratory failure. Immediate intervention is necessary. Increased crackles are usually associated with heart failure and are not an indication of respiratory failure. An increased respiratory rate indicates respiratory compromise, but not respiratory failure.

The nurse is collecting a health history for a 12-month-old child. The child lives in a home where both parents smoke, and the child has had respiratory syncytial virus twice since birth. The child's older sister was recently diagnosed with asthma. The nurse understands that this child's risk of developing asthma later in life is A) above average. B) average. C) below average. D) well below average.

A) Risk factors for asthma include exposure to air pollution, including secondary smoke from cigarettes, and early exposure to respiratory syncytial virus. Genetic factors may also play a role in asthma development. Because of the presence of these risk factors, this child has an above average risk of developing asthma later in life.

The nurse is providing care for a client admitted during an acute exacerbation of asthma. Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client? A) Inhaled short-acting beta-agonists B) Oral corticosteroids C) Inhaled long-acting beta-agonists D) Oral anticholinergics

A) The client admitted with an acute exacerbation of asthma will require a rescue medication, such as an inhaled short-acting beta-agonist. Oral corticosteroids, inhaled long-acting beta agonists, and oral anticholinergics are maintenance medications used to treat asthma.

The nurse is planning care for a client diagnosed with acute kidney injury (AKI). The nurse plans the client's care based on the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis? A) Pitting edema in the lower extremities B) Bowel sounds positive in four quadrants C) Wheezing in the lungs D) Generalized weakness

A) The client in acute kidney injury (AKI) will likely be edematous, because the kidneys are not producing urine. Wheezing in the lungs is an assessment consistent with asthma, not AKI. Bowel sounds in four quadrants is a normal assessment finding. Generalized weakness may be due to whatever disease process precipitated the kidney failure.

Which symptom suggests that a client is entering the maintenance phase of acute kidney injury (AKI)? A) Onset of metabolic acidosis B) Onset of diuresis C) Increase in glomerular filtration rate D) Decrease in serum potassium levels

A) The maintenance phase of AKI is characterized by a significant fall in glomerular filtration rate (GFR) and tubular necrosis. Oliguria, azotemia, fluid retention, electrolyte imbalances, and metabolic acidosis may all develop. Also during this phase, impaired potassium excretion leads to hyperkalemia, or increased serum potassium levels. Onset of diuresis and an increasing glomerular filtration rate are suggestive of the recovery phase, not the maintenance phase.

An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to be prescribed for this client? A) Beta blocker B) Digoxin C) Nitrate medications D) Fluids

A) Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Digoxin should be avoided because it increases the force of contractions. Nitrates should be avoided because they increase blood pressure. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.

Vaccinations can help promote healthy oxygenation by A) reducing the transmission of preventable diseases. B) increasing the exchange of oxygen for carbon dioxide in the lungs. C) promoting adequate blood circulation to organs and tissues. D) preventing all respiratory infections.

A) Vaccinations help decrease the transmission of preventable diseases, many of which are spread by respiratory secretions. Many of these diseases also affect the respiratory system and can alter oxygenation. Vaccinations do not directly increase the exchange of oxygen for carbon dioxide in the lungs, nor do they promote adequate blood circulation. Vaccinations can prevent some respiratory infections, but not all respiratory infections, and they can also prevent some nonrespiratory infections.

The nurse is caring for a client diagnosed with acute kidney injury (AKI). When reviewing the client's laboratory data, which findings should indicate to the nurse that the client has met the expected outcomes? Select all that apply. A) Decreasing serum creatinine B) Decreasing blood urea nitrogen (BUN) C) Decreasing neutrophil count D) Decreasing lymphocyte count E) Decreasing erythrocyte count

A, B) Creatinine is the metabolic end product of creatine phosphate and is excreted via the kidneys in relatively constant amounts. BUN, a measurement of the nitrogen portion of urea, is also excreted in urine and is a good indicator of renal function. Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal function.

The nurse is concerned that an older adult client is at risk for developing acute kidney injury (AKI). Which data in the client's history supports the nurse's concern? Select all that apply. A) Diagnosed with hypotension B) Recent aortic valve replacement surgery C) Prescribed high doses of intravenous antibiotics D) Total hip replacement surgery 5 years ago E) Taking medication for type 2 diabetes mellitus

A, B, C) Older adults develop acute kidney injury more frequently because of the higher incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts the older client at risk for acute kidney injury. Hypotension, aortic valve replacement surgery, and receipt of high doses of intravenous antibiotics increase this client's risk for developing acute kidney injury. A previous history of hip replacement surgery and current treatment for type 2 diabetes mellitus are not identified risk factors for the development of acute kidney injury.

The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will the nurse include in the teaching session? Select all that apply. A) Sepsis B) Viral pneumonia C) Drug overdose D) Near drowning in saltwater E) Fractured humerus

A, B, C, D) ARDS is a severe form of acute respiratory failure that occurs in response to pulmonary or systemic insults. Such insults include, but are not limited to, sepsis, pulmonary infections, saltwater inhalation, and drug overdose. A fractured humerus is not a risk factor for the development of ARDS.

Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply. A) Encouraging deep breathing exercises B) Assisting with positioning C) Providing suctioning D) Prescribing bronchodilators E) Monitoring activity intolerance

A, B, C, E) Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.

Which of the following triggers can stimulate an acute asthma attack? Select all that apply. A) Stress B) Animal dander C) Loud noises D) Exercise E) Bright lights

A, B, D) Stress, exercise, and animal dander are all known triggers of asthma. Loud noises may trigger hearing loss or headaches, but they will not trigger asthma. Bright lights are also not known to trigger asthma.

The nurse is providing care to a client admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS). When educating the client's family, what should the nurse say is the expected progression of the disease process? A) Initiation of ARDS B) Onset of pulmonary edema C) End-stage ARDS D) Alveolar collapse

A, B, D, C Explanation: ARDS begins with inflammatory cellular responses and biochemical mediators that damage the alveolar-capillary membrane. Increased interstitial pressure and damage to the alveolar membrane allow fluid to enter the alveoli. The inflammatory process damages surfactant-producing cells, leading to a deficit of surfactant, increased alveolar surface tension, and alveolar collapse. Multiple-organ system dysfunction of the kidneys, liver, gastrointestinal tract, central nervous system, and cardiovascular system are the leading causes of death in ARDS.

A client diagnosed with frequent urinary tract infections is seen in the urology clinic. The nurse reviews the client's medical history and determines that the client is at risk for acute kidney injury. Which items in the client's history support this conclusion? Select all that apply. A) Dehydration B) Renal calculi C) Ineffective wound healing D) Low serum albumin E) Hypertension

A, B, E) Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.

The postoperative nurse is planning care for a client recovering from major thoracic surgery. Which nursing diagnoses should the nurse select to plan for this client's immediate care needs? Select all that apply. A) Risk for Impaired Gas Exchange B) Risk for Decreased Cardiac Output C) Deficient Knowledge D) Risk for Imbalanced Nutrition: Less than Body Requirements E) Risk for Imbalanced Fluid Volume

A, B, E) Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. Deficient Knowledge is a diagnosis more appropriate to the preoperative phase before surgery. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase.

A client who is 4 days post-cholecystectomy has T-tube drainage totaling 600 mL in 24 hours. Which actions by the nurse are appropriate based on this data? Select all that apply. A) Notify the healthcare provider. B) Place the client in a supine position. C) Assess drainage characteristics. D) Clamp the tube q 2 hours for 30 minutes. E) Encourage increased fluid intake.

A, C) The T-tube may drain 500 mL in the first 24 hours and is expected to decrease steadily thereafter. If there is excessive drainage, as in this scenario, the nurse should further assess the drainage to be able to describe it accurately and notify the healthcare provider immediately. Clamping the tube would be contraindicated. Placing the client in a supine position and encouraging fluid intake are of no help.

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD). The client is admitted to the intensive care unit with a pneumothorax. Which interventions are appropriate for this client? Select all that apply. A) Elevate head of the bed B) Administer a high rate of oxygen by nasal cannula C) Prepare for a chest tube insertion D) Administer prescribed antihypertensive medications E) Administer intravenous caffeine per order

A, C) The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed because of the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia, which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.

The nurse is planning care for a young adolescent client diagnosed with asthma. Which evidence-based age-appropriate interventions will the nurse include in the plan of care? Select all that apply. A) Referring to a peer-led support group B) Teaching the parents how to administer maintenance medication prior to teaching the client C) Assessing peer support when planning care D) Collaborating with teachers for support in the school setting E) Telling the client to avoid medication while at school

A, C, D) Age-appropriate, evidence-based interventions for a young adolescent client diagnosed with asthma include referral to a peer-led support group, assessing peer support of the client, and collaborating with teachers to ensure the client has the necessary support in the school setting. While it is appropriate to include the parents in the educational process, the client should be taught how to administer medications prior to teaching the parents. Avoiding medication administration while in school could lead to an acute asthma attack.

The nurse is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply. A) Excessive rapid breathing B) Chest pain C) Rapid breathing at rest D) Shallow breathing E) Cyanosis

A, C, D) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.

The nurse is providing teaching to a client who is about to undergo surgery. When discussing whom the client can expect to see in the operating room suite, which individuals should the nurse include? Select all that apply. A) Surgeon B) Postoperative nurse C) Circulating nurse D) Anesthesiologist E) Social worker

A, C, D) The surgeon performs the procedure. The postoperative nurse will provide care to the client after the surgery is completed. The circulating nurse is a perioperative registered nurse who cares for the client during the surgical procedure. The anesthesiologist provides the anesthesia during the surgery and continually monitors the client's physiologic status. The social worker will not be in attendance during the procedure but may become involved in the client's care during the preoperative and postoperative phases.

A client with cholelithiasis is in the clinic for a follow-up assessment after hospitalization. What lifestyle modification should the nurse teach the client to decrease the pain associated with the disease process? A) Reduce sodium intake B) Decrease fat consumption C) Increase fluids D) Decrease smoking

B) A client who is experiencing cholelithiasis should be instructed on the relationship between increased fat consumption and the severity of pain associated with cholelithiasis. Although all clients should be instructed to reduce sodium intake, decreasing sodium will not assist in reducing cholelithiasis or its pain. Increasing fluids will not assist in reducing cholelithiasis or its pain. Also, while all clients should be encouraged to cease smoking, smoking has no relationship to cholelithiasis.

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this client? A) Risk for Infection B) Impaired Spontaneous Ventilation C) Risk for Acute Confusion D) Decreased Cardiac Output

B) A priority nursing intervention for a client with a respiratory rate of 8 breaths per minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the client could experience respiratory arrest. While the other nursing diagnoses may also be appropriate, they are not the priority for this client.

A prothrombin time (PT) test measures which of the following? A) Time required for the client's blood to clot B) Time required for the client's plasma to clot C) Time required for platelets to effectively stop bleeding D) Time required for a surgical procedure

B) A prothrombin time (PT) test measures the time required for the client's plasma to clot. A partial thromboplastin time (PTT) test measures the time required for the client's blood to clot. A bleeding time test measures the time required for platelets to effectively stop bleeding. No diagnostic test measures the time required for a surgical procedure.

The nurse is caring for a client admitted with a diagnosis of acute kidney injury (AKI). The client asks the nurse, "Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is the most appropriate? A) "No, don't think that. You're going to be fine." B) "In most cases, your condition can be reversed with prompt treatment and usually will not destroy the kidneys." C) "Kidney transplantation is highly likely, so it would be a good idea to start talking to your family members about organ donation." D) "When the doctor comes to see you, we can talk about whether you will need a transplant."

B) AKI is often resolved without the need for transplant if treatment is initiated quickly. There is no need to start lining up donors or wait for the provider to arrive to explore options. Telling the client that everything will be fine is condescending, provides no information, and is not within the nurse's ability to know.

The nurse is caring for an older adult client with cholecystitis. The client has been admitted to the hospital for diagnostic testing and pain control. Which nursing diagnosis would be of highest priority for this client? A) Anxiety B) Risk for Infection C) Impaired Comfort D) Imbalanced Nutrition: Less than Body Requirements

B) All of these diagnoses are appropriate for the client with gallbladder disease. However, because older adults do not have as effective an immune system as younger clients, the nurse should prioritize care around preventing infection in this client.

Which data supports the nurse's assessment that a newborn with acute respiratory distress syndrome (ARDS) is improving? A) Increased PaCO2 B) Oxygen saturation of 92% C) Pulmonary vascular resistance increases D) Thick secretions from the respiratory tract

B) An expected outcome for a client being treated for ARDS is maintaining an oxygen saturation of greater than 90%. The newborn diagnosed with ARDS with an oxygen saturation of 92% is improving. Increased PaCO2, increased pulmonary vascular resistance, and thick secretions from the respiratory tract are indicative of continued distress.

One primary method for preventing ARDS in hospitalized clients is A) performing postural drainage for clients with respiratory congestion. B) elevating the head of the bed for clients who are ingesting food. C) providing smoking cessation literature to clients who smoke. D) administering oxygen as ordered by the healthcare provider.

B) Aspiration of gastric contents is a major risk factor for developing ARDS. Therefore, simple interventions such as elevating the head of the bed for clients who are ingesting food can help prevent ARDS. Performing postural drainage and administering oxygen will not prevent ARDS. Although smoking may increase the risk for ARDS, it is not a direct cause of ARDS, so smoking cessation literature will not prevent ARDS in hospitalized clients.

The nurse is preparing a client for emergency surgery to repair liver and colon lacerations caused by a motor vehicle crash. Which information about this type of surgery will the nurse use to guide the client's care? Select all that apply. A) An organ is going to be removed. B) This is an emergency surgery. C) The client will be hospitalized longer. D) The client is at risk for blood loss. E) The client is at risk for hypothermia.

B, C, D, E) The client is having surgery to repair lacerations. No organ is identified for removal. Emergency surgery is performed when a condition is life threatening. Surgery to control internal hemorrhage from lacerations is an example of emergency surgery. An open procedure usually requires a longer hospital stay. Open procedures place the client at a higher risk for blood loss. Larger incisions place the client at a higher risk for complications, such as hypothermia and surgical site infections (SSIs).

The nurse is caring for an older adult client with gallbladder disease who is recovering from a cholecystectomy. Which risk factors increase this client's susceptibility to infection? Select all that apply. A) Dry skin B) Advanced age C) Intact mucous membranes D) Nonintact skin E) Active bowel sounds

B, D) This client is more susceptible to infection due to advanced age and the presence of a surgical incision. A surgical incision indicates that the body's first line of defense, the skin, is not intact. Active bowel sounds, dry skin, and intact mucous membranes are all factors that help defend the body against infection.

A client with acute respiratory distress syndrome (ARDS) is being weaned from ventilatory support. Which nursing actions are appropriate for this client? Select all that apply. A) Increase percentage of oxygen being provided through the ventilator. B) Place in the Fowler position. C) Provide morning care during the weaning procedures. D) Begin weaning procedures in the morning. E) Medicate with morphine for pain as needed.

B, D) Weaning a client from ventilatory support should begin in the morning when the client is well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. Activities and care should be limited during the weaning process to reduce the demand for oxygen. The client should not be given any medication known to suppress respirations, as this would interfere with the weaning process. The percentage of oxygen is typically reduced during the weaning process.

The postoperative care nurse is reviewing the documentation from the intraoperative phase of a client's surgical procedure. Which information should the nurse anticipate finding on the intraoperative documentation? Select all that apply. A) Pain assessment B) Start and stop times of anesthesia C) Medication review D) Antibiotic infusion times E) Start and stop times of the procedure

B, D, E) Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. The pain assessment and medication review are documented during both the preoperative and postoperative assessments.

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations are the direct result of altered perfusion? Select all that apply. A) Bounding pulse B) Pink nail beds C) Cyanosis D) Confusion E) Wheezing

C) A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion. A weak pulse and blue nail beds would also indicate poor perfusion. Wheezing is an abnormal breath sound that is the result of excess mucus in the airways.

How often should a client be monitored during the intraoperative phase? A) Every 5 minutes B) Every 30 minutes C) Constantly D) Occasionally

C) Constant monitoring of both the surgical environment and the client is necessary to ensure client safety. Monitoring the client every 5 minutes, every 30 minutes, or just occasionally could miss an important change in the client's status that could result in client harm or adverse complications.

The nurse is caring for a client admitted with septic shock. Which early clinical manifestation might indicate the development of ARDS? A) Intercostal retractions B) Cyanosis C) Tachypnea D) Tachycardia

C) Dyspnea and tachypnea are early clinical manifestations of ARDS. As the distress progresses, the client would demonstrate an increasing respiratory rate, intercostal retractions, and use of accessory muscles, as well as tachycardia. Cyanosis is a late manifestation.

A client asks why asthma medication is needed even though the client's last attack was several months ago. Which response by the nurse is appropriate? A) "The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack." B) "The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him." C) "The medication is still needed to decrease inflammation in your airways and help prevent an attack." D) "The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it."

C) Effective treatment of asthma includes long-term treatment to prevent attacks and decrease inflammation, as well as short-term treatment when an attack occurs. Long-term treatment of asthma continues indefinitely, not for just 1 year. Telling a client that lungs will be severely damaged is nontherapeutic; the inability to prevent an acute attack in this client is not true. The nurse is able to answer the client's question; it does not need to be referred to the physician.

A client diagnosed with recurrent urinary tract calculi would be at elevated risk for which of the following types of acute kidney injury (AKI)? A) Prerenal AKI B) Intrinsic AKI C) Postrenal AKI D) Intrarenal AKI

C) Obstructive causes of AKI are classified as postrenal. Any condition that prevents urine excretion—including urinary tract calculi—can lead to postrenal AKI. In comparison, prerenal AKI results from conditions that affect renal blood flow and perfusion, and intrinsic AKI (also called intrarenal AKI) is characterized by acute damage to the renal parenchyma and nephrons.

A client with terminal cancer is undergoing surgery to partially remove a tumor that is pressing on a nerve and causing pain. This is classified as what type of surgery? A) Reconstructive B) Diagnostic C) Palliative D) Emergency

C) Palliative surgery may be performed to alleviate pain or symptoms associated with a disease, and so this client's surgery, because it involves partially removing a tumor causing severe pain, is most illustrative of palliative surgery. Reconstructive surgery is to restore lost or reduced appearance or function. A diagnostic procedure would be conducted to determine or confirm a diagnosis. Emergency surgery is to save life or limb.

The nurse is providing care to a client with sepsis due to a severely infected leg wound. The client states that he is having trouble breathing. Upon assessment, the nurse notes dyspnea, a respiratory rate of 32, the use of accessory muscles to breathe, and rales and rhonchi upon auscultation of the lungs. The nurse recognizes these findings as characteristic of what condition? A) Allergic response from antibiotic therapy B) Deep vein thrombosis C) Acute respiratory distress syndrome D) Anemia

C) Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The client has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. Pulmonary assessment data indicate that the client is developing acute respiratory distress. Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS.

The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion? A) P wave smooth and round B) Absent U wave C) PR interval 0.30 seconds D) ST segment isoelectric

C) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The U wave is not normally seen. The ST segment should be isoelectric.

The structure of the respiratory system that serves as the site of gas exchange is the A) macrophage. B) bronchi. C) alveoli. D) bronchiole.

C) The alveoli comprise the terminal structures of the lower respiratory system. Alveoli serve as the sites of gas exchange, specifically, carbon dioxide and oxygen. Bronchi and bronchioles are larger structures in the respiratory system that serve as tracts for airflow. Macrophages are immune cells that keep the alveoli region free of microbes.

A client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate? A) Ineffective Airway Clearance B) Impaired Tissue Perfusion C) Ineffective Breathing Pattern D) Activity Intolerance

C) The client is experiencing an increased respiratory rate and is wheezing, which is an ineffective breathing pattern. Not enough information is provided to determine whether the client has ineffective airway clearance, activity intolerance, or impaired tissue perfusion.

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance. Which action by the nurse is the most appropriate? A) Encourage strenuous activity. B) Consult a dietitian for low-calorie meals. C) Space periods of activity with periods of rest. D) Encourage dependence with activities of daily living.

C) The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. It will often be appropriate to space periods of activity with periods of rest. Clients with respiratory disorders often need an increase, not a decrease, in calories to maintain body functions. The client will be weak, so the nurse should not encourage strenuous activity. The nurse would want the client to be as independent as possible and would not encourage dependence with activities of daily living.

When auscultating the lungs of a client experiencing dyspnea, the nurse hears a low-pitched sound that is continuous throughout inspiration. What does this lung sound indicate to the nurse? A) Narrow bronchi B) Narrow trachea passages C) Blocked large airway passages D) Inflamed pleural surfaces

C) The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.

A client diagnosed with acute kidney injury (AKI) is receiving peritoneal dialysis. The nurse is explaining the dialysis process to the client and family. Which statement should the nurse include in this discussion? A) "The peritoneum is more permeable because of the presence of excess metabolites." B) "The metabolites will diffuse from the interstitial space to the bloodstream mainly through diffusion and ultrafiltration." C) "The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis." D) "The solutes in the dialysate will enter the bloodstream through the peritoneum."

C) The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion using the peritoneum as the semipermeable membrane.

The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy. The client wants to know why her doctor told her she had an extra heart sound at the last visit. Which response by the nurse is appropriate? A) "You will need to have an echocardiogram to determine the reason for the extra sound." B) "You are likely experiencing heart failure due to the extra fluid that accumulates during this time in pregnancy." C) "You have what is known as a ventricular gallop, and it can be a normal finding during this trimester of pregnancy." D) "You have what is known as atrial gallop, and this is cause for concern."

C) Two other heart sounds may be present in some healthy individuals. The third heart sound (S3) may be heard in children, in young adults, or in pregnant females during the third trimester. It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound during diastole. There is no need for an echocardiogram. While the S3 sound can be associated with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can also be present in health individuals.

The nurse is reviewing discharge instructions with a client who is newly diagnosed with asthma. Which client statement indicates a need for further teaching? A) "I need to rinse my mouth after every use of my inhaler." B) "I need to take my Singulair at least 1 hour before I eat." C) "When inhaling two different medications, I should use the bronchodilator last." D) "Because I am on theophylline, I will need to have therapeutic blood levels drawn."

C) When using two different medications taken by inhalation, the bronchodilator should always be used first. This helps open the airways to enhance the effectiveness of the second medication. The other statements are accurate and require no further education.

While receiving report from the operating room, the nurse learns that a client's surgical wound after gallbladder removal is classified as III. What does this classification tell the nurse? Select all that apply. A) The alimentary tract was not entered. B) The wound is necrotic and infected. C) Gallbladder contents spilled into the surgical site. D) A break in sterility occurred during the surgery. E) The alimentary, respiratory, genital, or urinary tract was entered.

C, D) An incision is classified as III—contaminated if gross spillage from the GI tract occurred. This classification is also identified if a major break in sterile technique occurred. An incision is classified as I—clean if the alimentary, respiratory, genital, and urinary tract are not entered. An incision is classified as IV—dirty, infected if the wound is necrotic and infected. An incision is classified as II—lean contaminated if there are no signs of infection but the alimentary, respiratory, genital, or urinary tracts were entered.

Which statements are correct regarding the various layers of the heart? Select all that apply. A) The endocardium covers the entire heart and great vessels. B) The endocardium is the muscular layer of the heart that contracts during each heartbeat. C) The outermost layer of the heart is the epicardium. D) The myocardium consists of myofibril cells. E) The myocardium has four layers.

C, D) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.

Friends of a client hospitalized with asthma would like to bring the client a gift. Which gift should the nurse recommend for this client? A) A basket of flowers B) A stuffed animal C) Fruit and candy D) A book

D) A client with asthma must not be exposed to items that can exacerbate their disease process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and items that may contain dust, such as a stuffed animal, should be avoided. Objects void of irritants, such as a book, would be an appropriate gift.

The nurse assigned to the newborn nursery is conducting shift assessments. While assessing one newborn, the nurse notes the respiratory rate is 52 breaths per minute. Which action by the nurse is appropriate? A) Notify the healthcare provider of this assessment finding. B) Obtain an arterial blood gas for further respiratory assessment. C) Begin monitoring the respiratory rate every 5 minutes. D) Continue to monitor the newborn per facility policy.

D) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute. Therefore, this client only needs monitoring. No other actions are necessary.

What is characteristic of assessment in perioperative care? A) It is primarily a component of preoperative care. B) It is used most often during the intraoperative process. C) It primarily is involved in evaluating clients during postoperative care. D) It is involved in every part of the perioperative process.

D) Assessment is the most significant concept during the perioperative process and encompasses most of the other concepts. In addition to monitoring the client's vital signs and taking into account the spiritual, cultural, and emotional aspects of a client's care, assessment may include a nurse's communication with the healthcare and surgical team. Assessing what other team members gather from a nurse's communication is vital to a client's safety.

The nurse is caring for a woman who is 32 weeks pregnant and requires mechanical ventilation for ARDS. In addition to standard nursing interventions for adult clients with ARDS, what special interventions need to be implemented for this client? A) Inducing labor B) Administering nitric oxide and corticosteroids C) Providing nutritional support D) Fetal monitoring

D) Care for pregnant clients with ARDS who are at least at 20-24 weeks' gestation should include close fetal monitoring for potential emergency delivery. If the ARDS leads to compromised placental oxygen transfer, the neonate should be delivered immediately for the best outcome. However, not all pregnant women with ARDS will need immediate emergency delivery of the neonate. Providing nutritional support and administering nitric oxide and corticosteroids are interventions for all adult clients with ARDS, not only pregnant women.

A young school-age client is in the hospital with an acute kidney injury diagnosis following a streptococcus infection. The client's parents primarily speak Spanish but have a limited ability to understand English. Through an interpreter, the parents ask the nurse what mistake they made that caused their child to be so sick. Which response by the nurse is the most appropriate? A) "Your child does not eat enough dietary protein." B) "Your child has a congenital defect that led to renal failure." C) "Your child's renal failure has been caused by a low calcium level." D) "Your child's recent infection may have caused the renal failure."

D) Clients with streptococcus are at risk for kidney and cardiac sequelae. In this case, the child has no evidence of a congenital defect leading to acute kidney injury (AKI). A low-protein or low-calcium diet will not lead to AKI.

Which clinical manifestation does the nurse correctly attribute to hypoxia in a client with acute respiratory distress syndrome (ARDS)? A) Fluid imbalance B) Hypertension C) Bradycardia D) Dyspnea

D) Dyspnea is a clinical manifestation of clients experiencing hypoxia secondary to ARDS. Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with ARDS. The nurse would expect tachycardia, not bradycardia, as a result of hypoxia.

A client agrees to receive long-term hemodialysis to treat acute kidney injury (AKI). Based on this information, the nurse should prepare the client for which surgical procedure? A) Insertion of a double-lumen catheter into the subclavian artery B) Placement of a peritoneal catheter C) Insertion of a subarachnoid-peritoneal shunt D) Placement of an arteriovenous fistula

D) For long-term vascular access needed for hemodialysis, an arteriovenous (AV) fistula is created. The fistula is created by surgical anastomosis of an artery and vein, usually the radial artery and cephalic vein. It takes about a month for the fistula to mature so that it can be used for taking and replacing blood during dialysis. A double-lumen catheter inserted into a major artery is used as temporary vascular access for continuous renal replacement therapy. A peritoneal catheter is used for peritoneal dialysis, not hemodialysis. A subarachnoid-peritoneal shunt is used to remove excess cerebrospinal fluid and not for hemodialysis.

The nurse is planning care for a client admitted with a diagnosis of heart failure. Based on this diagnosis, which type of kidney failure is the client at an increased risk for experiencing? A) Prerenal hypovolemia B) Intrarenal glomerular injury C) Intrarenal acute tubular necrosis D) Prerenal low cardiac output

D) Heart failure is one possible cause of prerenal kidney failure due to low cardiac output. In comparison, causes of prerenal kidney failure due to hypovolemia include hemorrhage, dehydration, burns, wounds, and excess fluid loss from the gastrointestinal tract. Causes of intrarenal kidney failure due to glomerular injury include glomerulonephritis, disseminated intravascular coagulation, vasculitis, hypertension, toxemia of pregnancy, and hemolytic uremic syndrome. Finally, causes of intrarenal kidney failure due to acute tubular necrosis include ischemia resulting from conditions associated with prerenal failure, toxins, hemolysis, and rhabdomyolysis.

Which medication is used to increase renal blood flow in clients with acute kidney injury? A) Furosemide (Lasix) B) Mannitol (Osmitrol) C) Bumetanide (Bumex) D) Dopamine (Intropin)

D) In clients with acute kidney injury, dopamine (Intropin) is administered in low doses by intravenous infusion to increase renal blood flow. If restoration of renal blood flow does not improve urinary output, a potent loop diuretic, such as furosemide (Lasix) or bumetanide (Bumex), or an osmotic diuretic, such as mannitol (Osmitrol), may be given with intravenous fluids. These medications help "wash" nephrotoxins out of the kidneys and reestablish urine output.

Which of the following lab results suggests that a client with gallbladder disease is experiencing obstructed bile flow in the biliary duct system? A) Decreased WBC count B) Elevated WBC count C) Decreased direct bilirubin D) Elevated direct bilirubin

D) In clients with gallbladder disease, elevated direct bilirubin may indicate obstructed bile flow in the biliary duct system. Although clients with gallbladder disease often have an elevated WBC count, this result is suggestive of infection and inflammation rather than obstructed bile flow.

The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function. Which laboratory finding would be most significant for this client? A) Hemoglobin level 14 g/dL B) Oxygen saturation 96% C) Serum sodium 140 mg/dL D) Blood pH 7.32

D) Normal blood pH is 7.35-7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation. The serum sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. Oxygen saturation of 96% is within normal limits.

The nurse is providing care to a client with asthma. When developing the client's plan of care, which intervention would be most appropriate to promote effective gas exchange? A) Provide adequate rest periods B) Reduce excessive stimuli C) Assist with activities of daily living D) Place in Fowler position

D) Placing in Fowler position facilitates breathing and lung expansion, promoting airway clearance. Providing adequate rest periods prevents fatigue and reduces oxygen demands. Reducing excessive stimuli promotes rest. Assisting with activities of daily living conserves energy and reduces oxygen demands.

The nurse is evaluating care provided to an older adult client with a history of cholecystitis 5 months ago. Which of the following statements on the part of the client indicates that the client met a goal in the plan of care? A) "I have increased my intake of fat." B) "I have been eating out often." C) "I have been walking 1 mile every day." D) "I have been able to gain 5 pounds on the new diet."

D) The older adult client with cholecystitis is at elevated risk for infection. Thus, a goal would be to stabilize or increase weight through appropriate dietary measures to support the client's immune system and resist infection. Exercise is excellent but does not directly support this goal. Eating out would not be a goal for a client being treated for cholecystitis. The client would want to decrease fat intake.

The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). The client is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a decrease of cardiac output secondary to positive pressure ventilation? A) Blood pressure increases from 88/58 mmHg to 90/60 mmHg B) Urine output decreases from 30 mL/hr to 25 mL/hr C) Heart rate drops from 108 bpm to 104 bpm D) Oxygen saturation increases from 82% to 90%

B) Reduced cardiac output results in reduced perfusion of the kidneys, with a resulting decrease in urine output. Expected urine output is at least 30 mL/hr. This client's urine output is decreased; therefore, this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, both indicate improvement from the previous assessment, suggesting that they are not contributing to decreased cardiac output. The oxygen saturation level is within normal limits for this client and improving from the previous assessment.

Which of the following lifestyle changes would most likely increase a client's risk for cholelithiasis? A) Reducing intake of high-fat foods B) Increasing intake of high-cholesterol foods C) Beginning a regular exercise routine D) Discontinuing use of hormonal birth control

B) Several factors increase a client's risk for gallbladder disease, including consuming foods that are high in fat and cholesterol and using medications that contain estrogen, such as hormonal birth control. Exercise can aid in weight control, thereby reducing a client's risk for gallbladder disease.

The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which of the following should be included in this teaching session? Select all that apply. A) Limit exercise to 15 minutes a day B) Reduce saturated fats in the diet C) Avoid cigarette smoking D) Wear elastic hose E) Limit fluid intake

B, C) Interventions that help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.

The nurse is providing teaching to a client who is scheduled to undergo surgery in 2 weeks. Which topics should the nurse include that will prepare the client to help reduce complications during the postoperative phase? Select all that apply. A) Maintaining a patent airway B) Deep breathing and coughing C) Caring for the surgical incision D) Managing constipation E) Managing pain

B, C, D, E) Maintaining a patent airway is a nursing action that is performed during and after surgery; the client would not need client teaching about how to maintain a patent airway. In the preoperative phase, when the client is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. This knowledge will help the client reduce complications after the surgery.

The nurse is preparing an older adult client for surgery. On which topics should the nurse focus when preparing this client's preoperative teaching? Select all that apply. A) Level of hearing B) Amount of anesthesia needed during surgery C) Teaching on deep breathing and coughing D) Plans for discharge care E) Actions to prevent pressure ulcers

A, C, D, E) Clients do not need teaching related to intraoperative anesthesia amounts. For the older client, make sure the client can hear the information to be presented or provide information through alternative means. Deep breathing and coughing assist in the prevention of pneumonia and other respiratory conditions related to surgery, and deep breathing and coughing education should start in the preoperative phase. The older client is going to need assistance once discharged and should have the necessary medical equipment such as walkers and raised toilet seats, assistance with transportation, or extended care. The older client could be at risk for pressure ulcer formation because of poor nutritional status, diabetes, cardiovascular illness, or a history of steroid use.

The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply. A) Increased CO2 B) Vasoconstriction C) Decreased O2 D) Decreased intracranial pressure (ICP) E) Increased pulse rate

A, C, E) Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO2). Vasodilatation, not vasoconstriction, occurs as a low pH results in relaxation of vascular smooth muscle by interrupting the normal function of calcium channels. Cerebral vasodilation results in increased intracranial pressure. The pulse rate increases in an attempt to compensate for oxygen deprivation.

While performing nasotracheal suctioning, the nurse notes the older adult client with an alteration in oxygenation is moving the head around and pulling at the nurse's hand to remove the suction catheter. Which actions by the nurse are appropriate? Select all that apply. A) Remove the suction catheter B) Lower the head of the bed C) Decrease the suction pressure D) Apply restraints to the client's arms and legs E) Hyperoxygenate the client

A, C, E) The older adult client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, decrease the suction pressure, and hyperoxygenate the client. Restraining the patient does not address the hypoxemia. The client should be in the Fowler or high-Fowler position.

A nurse is caring for a client with severe acute abdominal pain secondary to cholelithiasis. Which nursing actions promote effective pain management? Select all that apply. A) Withhold oral food and fluids. B) Insert nasogastric tube and connect to high suction. C) Educate the client about decreasing protein in the diet, because protein increases gallbladder contractions. D) Administer morphine, meperidine, or another opioid analgesic as ordered. E) Place the patient in supine position to relieve abdominal pain.

A, D) The pain associated with cholelithiasis can be severe. Nursing interventions that help promote effective pain management include withholding oral food and fluids and inserting a nasogastric tube connected to low suction if ordered. The nurse should educate the client about decreasing fat in the diet, because fat entering the duodenum initiates gallbladder contractions, causing pain when gallstones are in the ducts. Administering morphine, meperidine, or another opioid analgesic as ordered also aids in pain management. In addition, the nurse should place the patient in Fowler position, not supine, to decrease pressure on the inflamed gallbladder.

The community nurse visits the home of a young child who is home from school because of sudden onset of nausea, vomiting, and lethargy. The nurse suspects acute kidney injury (AKI). Which clinical manifestations support the nurse's suspicions? Select all that apply. A) Elevated blood pressure B) Postural hypotension C) Wheezing D) Edema E) Hematuria

A, D, E) Pediatric manifestations of acute kidney injury characteristically begin with a healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant illness or injury. These symptoms may include any combination of the following: nausea, vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension. Postural hypotension is a manifestation of acute kidney injury in an older person. Wheezing is not a manifestation of acute kidney injury.

The nurse is instructing a client who is prescribed ipratropium bromide (Atrovent) for asthma. Which should be included in this client's teaching? Select all that apply. A) Take no more than the prescribed number of doses each day. B) Rinse the mouth after taking this medication. C) Take on an empty stomach. D) Take with meals or a full glass of water. E) Use hard candy or drink extra fluids to help with a dry mouth.

A, E) Appropriate teaching for a client prescribed ipratropium bromide (Atrovent) includes only taking the prescribed number of doses each day to prevent a drug overdose and the use of hard candy or extra fluids to decrease dry mouth. The mouth does not need to be rinsed after taking this medication. This medication does not need to be taken with meals or a full glass of water, or on an empty stomach.

The postoperative recovery room nurse determines that a client in the postoperative phase of care can be transitioned to phase 2 of recovery. The client is able to take deep breaths and cough, is using oxygen to maintain a saturation of greater than 90%, is fully awake, has a systolic blood pressure that is 130 mmHg now but the preoperative systolic blood pressure was 100 mmHg, and is able to move all four extremities independently. Using the following scale, this client's Aldrete score is ________. The Aldrete score: Respiration 2 = Able to take deep breath and cough 1 = Dyspnea/shallow breathing 0 = Apnea O2 Saturation 2 = Maintains >92% on room air 1 = Needs O2 inhalation to maintain O2 saturation >90% 0 = Saturation <90% even with supplemental oxygen Consciousness 2 = Fully awake 1 = Arousable on calling 0 = Not responding Circulation 2 = BP 20% preop 1 = BP 20-49% preop 0 = BP 50% preop Activity 2 = Able to move 4 extremities 1 = Able to move 2 extremities 0 = Able to move 0 extremities

Answer: 8 Explanation: The Aldrete system is designed to assess a client's transition from phase 1 recovery to phase 2 recovery, from discontinuation of anesthesia until return of protective reflexes and motor function. The criteria of respirations, oxygen saturation, consciousness, circulation, and activity are scored. The maximum score is 10. This client scores a 2 for respiration, a 1 for oxygen saturation, a 2 for consciousness, a 1 for circulation (roughly a 25% increase in blood pressure over preop BP, and a 2 for activity for a total of 8. Clients who score ≥8 are considered fit for transition to phase 2 recovery.

The nurse is caring for a 72-year-old client who has presented to the emergency department for the third time in 8 months with acute asthma exacerbations. The client states that he has trouble holding his inhaler, and sometimes he forgets to take his medication. He is also worried because he thinks his new drugs are adversely interacting with medications for his other conditions. What nursing diagnosis is appropriate for this client? A) Deficient Knowledge B) Ineffective Health Management C) Risk for Aspiration D) Ineffective Coping

B) Based on his repeated trips to the emergency department, his reported trouble holding his inhaler, and his inconsistency with taking his medications, an appropriate nursing diagnosis for this client is Ineffective Health Management. The client appears to have adequate knowledge about how to cope with his diseases; he is just unable to follow through with managing his medications at all times. Therefore, Deficient Knowledge and Ineffective Coping are not appropriate diagnoses based on this information. Not enough information is provided to determine if the client is at risk for aspiration.

The nurse instructs a client with asthma on bronchodilator therapy. Which statement indicates client understanding of how the drug works? A) "The medication widens the airways by causing airway muscle contraction." B) "The medication widens the airways by causing airway muscle relaxation." C) "The medication widens the airways by decreasing histamine production." D) "The medication widens the airways by decreasing mucus production."

B) Bronchodilators stimulate bronchiolar smooth muscle relaxation, not contraction. Smooth muscle relaxation increases the diameter of the airway lumen to enhance airflow. Bronchodilators do not decrease the production of mucus or the production of histamine.

Which of the following medications is used to reduce the cholesterol content of gallstones and lead to their gradual dissolution? A) Cholestyramine B) Chenodiol C) Meperidine D) Amoxicillin

B) Chenodiol (Chenix) is administered to reduce the cholesterol content of gallstones and lead to their gradual dissolution. These drugs act by reducing cholesterol production in the liver, thus reducing the cholesterol content of bile. In comparison, cholestyramine (Questran) is administered to relieve jaundice and pruritus related to accumulation of bile salts on the skin; meperidine is given to alleviate pain; and amoxicillin is given to reduce the likelihood of infection.

A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents indicates effective teaching? A) "We'll be sure to use the fireplace often to keep the house warm in the winter." B) "We will replace the carpet in our child's bedroom with tile." C) "We'll keep the plants in our child's room dusted." D) "We're glad the dog can continue to sleep in our child's room."

B) Control of dust in the child's bedroom is an important aspect of environmental control for asthma management, and replacing the carpeting in the child's bedroom with tile flooring will reduce dust. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

What is the most frequent complication during hemodialysis? A) Hemorrhage B) Hypotension C) Localized infection D) Hypertension

B) Hypotension is the most frequent complication during hemodialysis. It may result from changes in serum osmolality, rapid removal of fluid from the vascular compartment, vasodilation, and other factors. Bleeding is another possible complication, although it does not occur as often as hypotension. Infection is also commonly associated with hemodialysis, although it occurs following treatment rather than during dialysis.

The pathophysiologic stimulus that initiates asthma is A) bronchoconstriction. B) inflammation in the airways. C) airway edema. D) mucus secretion.

B) In asthma, the airways are in a persistent state of inflammation. This inflammation can lead to bronchoconstriction, airway edema, and increased mucus secretion. Therefore, inflammation is the primary stimulus that initiates asthma.

A client diagnosed with acute kidney injury (AKI) has jugular vein distention, lower extremity edema, and elevated blood pressure. Based on this data, which nursing diagnosis is most appropriate? A) Ineffective Renal Tissue Perfusion B) Excess Fluid Volume C) Risk for Decreased Cardiac Tissue Perfusion D) Risk for Infection

B) Jugular vein distention, edema, and elevated blood pressure are all indications of excess fluid. Thus, the diagnosis Excess Fluid Volume should be selected to guide this client's care. Oliguria or reduced urine output would be a symptom associated with Ineffective Renal Tissue Perfusion. Alterations in heart rate and rhythm would be symptoms associated with Risk for Decreased Cardiac Tissue Perfusion. The client is not demonstrating any manifestations that indicate a Risk for Infection.

The nurse is caring for a client who is scheduled to receive metoprolol (Lopressor). What should the nurse teach the client about this medication? A) Expect a rapid heart rate. B) Change positions slowly. C) Reduce protein intake. D) Increase fluids.

B) Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly because this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. Protein restriction is not indicated with this medication. The client should not be instructed to increase fluids.

The nurse is caring for a client who was admitted to the hospital 1 day prior with cholelithiasis. Which new assessment finding indicates that the stone has probably obstructed the client's common bile duct? A) Nausea and vomiting B) Jaundice C) Right upper quadrant (RUQ) pain D) Elevated cholesterol level

B) Nausea and RUQ pain occur in cystic duct disease, but obstruction of the common bile duct results in reflux of bile into the liver, which produces jaundice. Cholesterol levels do not increase with biliary obstruction.

Which laboratory finding suggests that a client is experiencing acute kidney injury (AKI) as a result of glomerular damage? A) Hyperkalemia B) Proteinuria C) Urine specific gravity of 1.010 D) Moderate anemia

B) Proteinuria, or excess protein in the urine, is suggestive of glomerular damage as the cause of a client's AKI. Urine specific gravity of 1.010, moderate anemia, and hyperkalemia are common laboratory findings in clients with AKI, regardless of its cause.

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma. Which action by the newly licensed nurse requires immediate intervention? A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler. B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment. C) The newly licensed nurse is observed assessing the client's thoracic wall, skin, and nail beds. D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.

B) The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client's thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client's breath sounds with the use of a stethoscope is appropriate.

The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem? A) Encouraging ambulation every 30 minutes B) Instructing on deep breathing C) Administering medications appropriate to increase heart rate D) Positioning to increase blood return

B) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest should occur between activities, and no activity should be too strenuous. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which would negatively impact oxygenation.

A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen 24% 2 L/min. Which is the best method to administer oxygen to this client? A) Face mask B) Nasal cannula C) Nonrebreather mask D) Venturi mask

B) The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.

The client with ARDS who is likely to have the poorest outcome is A) a Hispanic male with pneumonia. B) an African American male with sepsis. C) a Caucasian female with sepsis. D) an African American female with chest trauma.

B) The risk for mortality from ARDS is greater for men than for women, and it is greater for African Americans than people from other races. In addition, clients who develop ARDS from sepsis have poorer outcomes than clients who develop ARDS from pulmonary infections or trauma. Therefore, the African American male with ARDS from sepsis will likely have the poorest outcome.

Which of the following statements best describes the vital signs the nurse collects during the preoperative phase? A) They are the only vital signs collected during the perioperative period. B) When later vital signs are taken, they are compared against the preoperative set. C) Generally preoperative vital signs are only relevant during the intraoperative process. D) These are not essential and may be omitted for emergency surgeries.

B) Vital signs, including blood pressure, pulse, respiration, and oxygen saturation, should be taken throughout the perioperative period, with the baseline vital signs being obtained during the preoperative phase. Later vital signs will be compared against this baseline. Preoperative vital signs are not the only vital signs collected during the perioperative period, they are relevant through the perioperative period as a baseline, and they are important to record for any client.

The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse? A) At the fifth intercostal space B) At the left nipple C) At the right nipple D) At the eighth intercostal space

B) When assessing a pediatric client, it may be more beneficial to auscultate the apical pulse in the area of the left nipple at the fourth intercostal space. The other answer options are not appropriate.

The nurse is providing care to a client with ARDS who has a tracheostomy. The nurse will monitor the client for complications related to the loss of which protective mechanism? A) The ability to cough B) Filtration and humidification of inspired air C) Decrease in oxygen-carrying capacity of the trachea D) The sneeze reflex initiated by irritants in the nasal passages

B) When the nasal passages are bypassed, as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming provided by the nasal passages are also bypassed. The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.

A client admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). The nurse anticipates the healthcare provider will prescribe which course of action with regard to oxygenation? A) Oxygen via a nasal cannula B) Mechanical ventilation C) Oxygen via a face mask D) Oxygen via a Venturi mask

B) With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone. Therefore, mechanical ventilation is often necessary. Oxygen administered via nasal cannula, face mask, or venture mask all require active and adequate breathing by the client, which may not be possible for the client with ARDS.

A client receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety related to having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select all that apply. A) Explain about care areas specifically designed for long-term ventilatory support. B) Dim the lights and reduce distracting noise, such as the television. C) Instruct that intubation and ventilation are temporary measures. D) Encourage family visits and participation in care. E) Remain with the client as much as possible.

C, D, E) A critical illness creates anxiety for any client. For the client with ARDS, anxiety is compounded by intubation and mechanical ventilation. To reduce this client's anxiety, the nurse should encourage the family to visit and participate in care. The nurse should also remain with the client as much as possible and instruct that intubation and ventilation are temporary measures to allow the lungs to rest and heal. Explaining that there are care areas designed for long-term ventilatory support could increase the client's anxiety. The nurse should provide distractions such as television or radio and not dim the lights or turn off the television, which could also increase the client's anxiety.

The nurse is providing care to a client admitted after experiencing an acute asthma attack. Which assessment findings should the nurse identify as signs that the client has progressed to respiratory failure? Select all that apply. A) Retractions and fatigue B) Tachycardia and tachypnea C) Inaudible breath sounds D) Diffuse wheezing and the use of accessory muscles when inhaling E) Reduced wheezing and an ineffective cough

C, E) Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that the client is progressing to respiratory failure, and immediate interventions are necessary. During an asthma attack, tachycardia and tachypnea are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing, the use of accessory muscles when inhaling, retractions, and fatigue indicate a progression of the severity of the symptoms and may require nursing intervention, but they do not indicate respiratory failure.

A nurse was involved in the perioperative care of a preterm infant requiring cardiothoracic surgery. The infant has now been moved to the NICU. How should the nurse change the focus of her assessment in the postoperative phase? A) The nurse should assess the client as preterm. B) The nurse should assess the client's respiratory status. C) The nurse should assess the client's glucose levels. D) The nurse should assess the parents' coping mechanisms.

D) The postoperative infant client will most often be transferred to and cared for in the neonatal intensive care unit (NICU) at the facility at which the infant had the procedure. At this stage, the nurse should focus largely on support for the parents. Assessment of parents' grief, guilt, anxiety, and coping mechanisms is necessary so that the nurse may better assist the infant in receiving necessary care required from the parents. Assessing the client as preterm happens during preoperative care. Assessing the client's respiratory status is given special care during the transition into intraoperative care, and regulating the client's glucose levels happens during intraoperative care. Assessing the client in these areas would not be a change in focus for the nurse.

Which of the following situations demands that all perioperative staff cover their bodies with lead shields? A) The surgical team uses a bipolar handpiece to cauterize a client's tissue. B) The surgical team uses a class 3 laser to cut a client's kidney stone. C) The surgical team uses a pneumatic tourniquet to cut off circulation to a client's hand. D) The surgical team uses radiology to take intraoperative photos.

D) When radiology is used, perioperative staff must make sure lead shields cover their bodies, including women's ovaries and men's testicles, because radiation can cause sterility. Staff should also wear a neck shield to protect the thyroid gland. The other procedures do not involve radiation and don't require lead shields.