UNIT 3/4/5 prepu

Main triggers of acute pancreatitis is

-alcohol -gallstones -few days of hospilization

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate? a. Document and continue to monitor the parameters. b. Elevate the head of the patient's bed .c. Notify the health care provider about the assessments .d. Check the patient's pupillary response to light.

.c. Notify the health care provider about the assessments

Bilirubin is formed from the breakdown of: 1: Heme in red blood cells 2: Bile salts 3: Albumin 4: Globulins

1: Heme in red blood cells

During the liver biopsy, Mr. Green must be able to: 1: Lie on his side 2: Hold his breath while the biopsy needle is inserted 3: Have the procedure without sedation 4: Remain over night in the hospital

2: Hold his breath while the biopsy needle is inserted

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones? 1 to 4 months 4 to 6 months 6 to 12 months Over 1 year

6 to 12 months

You are providing care for a patient who has been admitted to the hospital with a head injury who requires regular neurologic vital signs. Which assessments are components of the patient's score on the Glasgow Coma Scale (select all that apply)? A. Eye opening B. Abstract reasoning C. Best verbal response D. Best motor response E. Cranial nerve function

A C D

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) a. fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

A, B, D, E-

GFR ESRD ARF CRF

GFR- Glomerular Filtration Rate. A blood test checks your GFR, which tells how well your kidneys are filtering. ESRD- Kidneys function at only or below 10 to 15 percent of their normal capacity, dialysis or a kidney transplant is necessary to live. ARF- Acute kidney failure occurs when your kidneys suddenly become unable to filter waste products from your blood. CRF- Chronic renal failure signifies loss of kidney function that occurs over a prolonged course of time as opposed to acute renal failure.

A client is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the client develops acute kidney injury. The client is hemodynamically unstable, and renal replacement therapy is needed to manage the client's hypervolemia and hyperkalemia. Which of the following therapies will the client's hemodynamic status best tolerate? Hemodialysis Peritoneal dialysis Continuous venovenous hemodialysis (CVVHD) Plasmapheresis

Continuous venovenous hemodialysis (CVVHD)

Which option indicates a sign of Cushing's triad, an indication of increased intracranial pressure (ICP)? A. Heart rate increases from 90 to 110 beats/minute B. Kussmaul respirations C. Temperature over 100.4° F (38° C) D. Heart rate decreases from 75 to 55 beats/minute

D

A client with end-stage kidney disease is scheduled to begin hemodialysis. The nurse is working with the client to adapt the client's diet to maximize the therapeutic effect and minimize the risks of complications. The client's diet should include which of the following modifications? Select all that apply. Decreased protein intake Decreased sodium intake Increased potassium intake Fluid restriction Vitamin D supplementation

Decreased protein intake Decreased sodium intake Fluid restriction

detection of ALP is important in

Detection of this ALP is important for determining liver and bone disorders.

Which phase of acute renal failure signals that glomerular filtration has started to recover? Diuretic Oliguric Initiation Recovery

Diuretic

A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by: Edema and inflammation Pleural effusion Sepsis Disseminated intravascular coagulopathy

Edema and inflammation

A client has been admitted to the hospital for the treatment of chronic pancreatitis. The client has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize? Educating the client about expectations and care following surgery Educating the client about the management of blood glucose after discharge Educating the client about postdischarge lifestyle modifications Educating the client about the potential benefits of pancreatic transplantation

Educating the client about postdischarge lifestyle modifications

Which of the following is the priority nursing diagnosis for the client in the oliguric phase of acute renal failure? Fluid volume excess Urinary retention Activity intolerance Disturbed body image

Fluid volume excess

The nurse is caring for a client whose acute kidney injury has prerenal cause. What most likely caused this client's health problem? Heart failure Glomerulonephritis Ureterolithiasis Aminoglycoside toxicity

Heart failure

A client is being cared for after a nephrectomy. Because of the incisional pain and restricted positioning, the client frequently suffers from breathing difficulty. Which measures should the nurse include in the care plan to relieve this distress? Select all that apply. Help the client to breathe deeply and cough every 2 hours. Provide firm support for the incision when the client coughs. Have client walk around the room as much as possible. Administer antibiotic therapy as prescribed.

Help the client to breathe deeply and cough every 2 hours. Provide firm support for the incision when the client coughs.

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the liklihood of liver problems? Select all that apply. Jaundice Petechiae Ecchymoses Cyanosis of the lips Aphthous stomatitis

Jaundice Petechiae Ecchymoses

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis? Shock Pancreatic necrosis MODS Tetany

Pancreatic necrosis

The nurse is caring for a client's status after a motor vehicle accident. The client has developed AKI. What are the nurse's roles in caring for this client? Select all that apply. Providing emotional support for the family Monitoring for complications Participating in emergency treatment of fluid and electrolyte imbalances Providing nursing care for primary disorder (trauma) Directing nutritional interventions

Providing emotional support for the family Monitoring for complications Participating in emergency treatment of fluid and electrolyte imbalances Providing nursing care for primary disorder (trauma)

The nurse is caring for a client who has just returned to the postsurgical unit following renal surgery. When assessing the client's output from surgical drains, the nurse should assess what parameters? Select all that apply. Quantity of output Color of the output Visible characteristics of the output Odor of the output pH of the output

Quantity of output Color of the output Visible characteristics of the output

A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider? Decreased breath sounds Drainage of bile-colored fluid onto the abdominal dressing Rigidity of the abdomen Acute pain with movement

Rigidity of the abdomen

A client is admitted to the ICU with acute pancreatitis. The client's family asks what causes acute pancreatitis. The critical care nurse knows that a majority of clients with acute pancreatitis have what? Type 1 diabetes An impaired immune system Undiagnosed chronic pancreatitis An amylase deficiency

Undiagnosed chronic pancreatitis

A 78-yr-old patient has stage 3 CKD and is being taught about a low-potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? a. Apple, green beans, and a roast beef sandwich b. Granola made with dried fruits, nuts, and seeds c. Watermelon and ice cream with chocolate sauce d. Bran cereal with ½ banana and milk and orange juice

a

e Which findings will the nurse expect when caring for a patient with chronic kidney disease (CKD)? Select all that apply a. Anemia b. Dehydration c. Hypertension d. Hypercalcemia e. Increased risk for fractures

a c e

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a. Loss of 2.2 lb (1 kg) in 24 hours b. Serum potassium level of 3.5 mEq/L c. Blood pH of 7.25 d. Serum sodium level of 135 mEq/L

a. Loss of 2.2 lb (1 kg) in 24 hours

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? a. Relieving abdominal pain b. Maintaining adequate nutritional status c. Teaching about the disease and its treatment d. Preventing fluid volume overload

a. Relieving abdominal pain

The home care nurse visits a 34-yr-old woman receiving peritoneal dialysis. Which statement indicates a need for immediate follow-up by the nurse? a. "Drain time is faster if I rub my abdomen." b. "The fluid draining from the catheter is cloudy." c. "The drainage is bloody when I have my period." d. "I wash around the catheter with soap and water."

b. "The fluid draining from the catheter is cloudy."

In replying to a patient's questions about the seriousness of her CKD, the nurse knows that the stage of CKD is based on what? a. total daily urine output b. GFR c. degree of altered mental status d. serum creatinine and urea levels

b. GFR

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

b. decreased pulse, irregular respiration, increased pulse pressure

What is the recommended dietary treatment for a client with chronic cholecystitis? a. low-residue diet b. low-fat diet c. high-fiber diet d. low-protein diet

b. low-fat diet

A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse a. examines the tympanic membrane for a tear b. tests the fluid for a halo sign on a white dressing c. tests the fluid with a glucose identifying strip or stick d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis

b. tests the fluid for a halo sign on a white dressing

A client has undergone a liver biopsy. After the procedure, the nurse should place the client in which position? a. On the left side b. Trendelenburg c. High Fowler d. On the right side

d

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? a. Creatinine b. Chloride c. Urobilinogen d. Albumin

d. Albumin

a way to treat acute pancreatitis is

hydrate the patient

A client's renal failure has become chronic. Which signs and symptoms are associated with chronic renal failure? Select all that apply. lethargy muscle cramps bleeding of the oral mucous membranes enhanced cognition

lethargy muscle cramps bleeding of the oral mucous membranes

An important feature of GGT is

that it can detect the presence of alcohol, even after a small amount of alcohol is ingested. Thus, the GGT test is important in the evaluation and management of alcoholism.

ALT is a more specific indicator of liver inflammation than the AST.

true

A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: water and sodium retention secondary to a severe decrease in the glomerular filtration rate. a decreased serum phosphate level secondary to kidney failure. an increased serum calcium level secondary to kidney failure. metabolic alkalosis secondary to retention of hydrogen ions.

water and sodium retention secondary to a severe decrease in the glomerular filtration rate.

What health promotion teaching should the nurse prioritize to prevent drug-induced hepatitis? Finish all prescribed courses of antibiotics, regardless of symptom resolution. Adhere to dosing recommendations of over-the-counter analgesics. Ensure that expired medications are disposed of safely. Ensure that pharmacists regularly review drug regimens for potential interactions.

Adhere to dosing recommendations of over-the-counter analgesics.

A female patient undergoes dialysis as a part of treatment for kidney failure. The patient is administered heparin during dialysis to achieve therapeutic levels. Which of the following steps should the nurse take to allow heparin to be metabolized and excreted in the patient? Avoid administering injections for 2 to 4 hours after heparin administration. Provide periods of rest throughout the day and uninterrupted sleep at night. Use dialysate solutions after 2 hours. Puncture the same site used previously.

Avoid administering injections for 2 to 4 hours after heparin administration.

You are caring for a patient admitted with a subdural hematoma after a motor vehicle accident. Which change in vital signs would you interpret as a manifestation of increased intracranial pressure? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

B

A nurse cares for a client with interstitial pancreatitis. What client teaching will the nurse include when planning care for the client? "Inflammation is confined to only the pancreas." "Normal function returns after about 2 weeks." "Inflammation spreads to the surrounding glands." "Tissue necrosis occurs within the pancreas."

"Inflammation is confined to only the pancreas."

A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this client's health problem? "Toxins have accumulated and inflamed your pancreas." "Bacteria likely migrated from your intestines and became lodged in your pancreas." "A virus that was likely already present in your body has begun to attack your pancreatic cells." "The enzymes that your pancreas produces have damaged the pancreas itself."

"The enzymes that your pancreas produces have damaged the pancreas itself."

The patient admitted with acute pancreatitis has passed the acute stage and is now able to tolerate solid foods. What type of diet will increase caloric intake without stimulating pancreatic enzymes beyond the ability of the pancreas to respond? Low-sodium, high-potassium, low-fat diet High-carbohydrate, high-protein, low-fat diet Low-carbohydrate, high-potassium diet High-carbohydrate, low-protein, low-fat diet

High-carbohydrate, low-protein, low-fat diet

x A client is experiencing a decreasing glomerular filtration. What laboratory values should the nurse expect to follow the change? Select all that apply. Serum creatinine increases Blood urea nitrogen (BUN) increases Creatinine clearance decreases Hypokalemia Hypophosphatemia

Serum creatinine increases Blood urea nitrogen (BUN) increases Creatinine clearance decreases

A client who has been having recurrent attacks of severe abdominal pain over the past few months informs the physician about a 25-pound weight loss in the past year. The nurse attributes which factor as the most likely cause of this weight loss? Vomiting after heavy meals Skipping meals out of fear of painful attacks Ingesting a low-fat diet to prevent abdominal pain Malabsorption

Skipping meals out of fear of painful attacks

A client with acute pancreatitis reports muscle cramping in the lower extremities. What pathophysiology concept represents the reason the client is reporting this? Tetany related to hypocalcemia Muscle spasm related to hypokalemia Muscle pain related to referred pain manifestations Tetany related to hypercalcemia

Tetany related to hypocalcemia

albumin concentration

The serum albumin concentration is usually normal in chronic liver disease until cirrhosis and significant liver damage has occurred.

Which complication of CKD is treated with erythropoietin? a. anemia b. hypertension c. hyperkalemia d. mineral and bone disorder

a. anemia

When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. Unlimited fluids are allowed since retained fluid is removed during dialysis .c. More protein will be allowed because of the removal of urea and creatinine by dialysis. d. Dietary sodium and potassium are unrestricted because these levels are normalized by dialysis.

c

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: a. Dextromethorphan b. Ibuprofen c. Acetaminophen d. Benadryl

c. Acetaminophen

What causes the GI manifestation of stomatitis in the patient with CKD? a. high serum sodium levels b. irritation of the GI tract from creatinine c. increased ammonia from bacterial breakdown of urea d. iron salts, calcium-containing phosphate binders, and limited fluid intake

c. increased ammonia from bacterial breakdown of urea

albumin 3

-Albumin, produced only in the liver, is the major plasma protein that circulates in the bloodstream. Albumin is essential for maintaining the oncotic pressure in the vascular system. A decrease in oncotic pressure due to a low albumin level allows fluid to leak out from the interstitial spaces into the peritoneal cavity, producing ascites.

The patient reports falling when he his foot got "stuck" on a crack in the sidewalk, hitting his head when he fell, and "passing out". The paramedics found the patient walking at the scene and talking before transporting the patient to the hospital. In the emergency department, the patient starts to lose consciousness. This is a classic scenario for which complication? A. Epidural hematoma B. Subdural hematoma C. Subarachnoid bleed D. Diffuse axial inju

A

Which dietary modification is used for a client diagnosed with acute pancreatitis? a. High-fat diet b. Low-carbohydrate diet c. Elimination of coffee d. High-protein diet

c. Elimination of coffee A high-carbohydrate, low-fat, and low-protein diet should be implemented. Alcohol, caffeine, and spicy foods should be avoided.

The objectives of nutrition therapy for chronic kidney disease are to reduce serum nitrogen levels, reduce hypertension and edema, prevent body catabolism, improve renal function, and prevent or delay the onset of complications. What would the nurse teach a client with chronic kidney disease to assist with dietary adherence. Select all that apply. Most protein should be from animal sources, which in general have a higher biologic value than plant proteins. Pure sugars and heart-healthy fats are used liberally for calories to spare body and dietary protein. Restrict protein intake to plant proteins because they are easier for the body to process. Restrict all sugars as the excess calories may be harmful to the kidneys.

Most protein should be from animal sources, which in general have a higher biologic value than plant proteins. Pure sugars and heart-healthy fats are used liberally for calories to spare body and dietary protein.

A 76-year-old client with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The client tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make? "The decision is certainly yours to make, but be sure not to make a mistake." "Kidney transplants in patients your age are as successful as they are in younger patients." "I understand your hesitancy to commit to a transplant surgery. Success is comparatively rare." "Have you talked this over with your family?"

"Kidney transplants in patients your age are as successful as they are in younger patients."

What is the most serious electrolyte disorder associated with kidney disease? a. hypocalcemia b. hyperkalemia c. hyponatremia d. hypermagnesemia

b

Mr. Green is scheduled to have a liver biopsy. Which of the following lab tests would be a contraindication for a liver biopsy? 1: An elevated ALT 2: A low serum albumin 3: A prolonged prothrombin time 4: An elevated GGT

3: A prolonged prothrombin time -liver is very vascular

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function? a. Fatigue durring ambulation b. Jaundice c. Pruritus of the arms and legs d. Irritability and drowsiness

d. Irritability and drowsiness

What initial measure can the nurse implement to reduce risk of injury for a client with liver disease? a. Prevent visitors, so as not to agitate the client b. Raise all four side rails on the bed c. Apply soft wrist restraints d. Pad the side rails on the bed

d. Pad the side rails on the bed-restlessness

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for: nausea and vomiting. dyspnea and cyanosis. fatigue and weakness. thrush and circumoral pallor.

fatigue and weakness.

A client has received a diagnosis of portal hypertension. What does portal hypertension treatment aim to reduce? Select all that apply. fluid accumulation venous pressure blood coagulation fluid output

fluid accumulation venous pressure

Because GGT is not increased in bone disease or bone growth, it can help differentiate liver disease

from skeletal disease when the ALP is elevated.

disadvantage of parcentsis for ascites is

A disadvantage of a parencentesis is that proteins are lost when the peritoneal fluid is drained

The nurse has instructed a patient who is receiving hemodialysis about appropriate dietary choices. Which menu choice by the patient indicates that the teaching has been successful? a. Scrambled eggs, English muffin, and apple juice b. Oatmeal with cream, half a banana, and herbal tea c. Split-pea soup, whole-wheat toast, and nonfat milk d. Cheese sandwich, tomato soup, and cranberry juice

a

When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. decorticate posturing. b. decerebrate posturing. c. localization of pain. d. flexion withdrawal.

a

A patient received a kidney transplant last month. Because of the effects of immunosuppressive drugs and CKD, what complication of transplantation should the nurse be assessing the patient for? a. infection b. rejection c. malignancy d. cardiovascular disease

a. infection

Which statement regarding continuous ambulatory peritoneal dialysis (CAPD) would be most important when teaching a patient new to the treatment? a. "Maintain a daily written record of blood pressure and weight." b. "It is essential that you maintain aseptic technique to prevent peritonitis." c. "You will be allowed a more liberal protein diet once you complete CAPD." d. "Continue regular medical and nursing follow-up visits while performing CAPD."

b. "It is essential that you maintain aseptic technique to prevent peritonitis."

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should a. monitor oxygen saturation. b. check arterial blood gases (ABGs). c. monitor intracranial pressure (ICP). d. assess patient breath sounds.

c

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as? a. Constructional apraxia b. Ataxia c. Asterixis d. Fetor hepaticus

c

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? a. Blood tinged b. Yellow-green c. Clay-colored or whitish d. Black and tarry

c

Which position should be used for a client undergoing a paracentesis? a. Prone b. Supine c. Upright at the edge of the bed d. Trendelenburg

c

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient slows the inflow rate when experiencing pain .b. The patient leaves the catheter exit site without a dressing. c. The patient plans 30 to 60 minutes for a dialysate exchange .d. The patient cleans the catheter while taking a bath every day.

d

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: a. Severe abdominal pain radiating to the shoulder b. Eructation and constipation c. Abdominal ascites d. Anorexia, nausea, and vomiting

d. Anorexia, nausea, and vomiting

Mrs. Jones is a 48-year-old woman admitted with symptoms of cholelithiasis. If gallstones are blocking the common bile duct, you would expect to see an increase in: 1: Albumin 2: Urobilinogen 3: Conjugated bilirubin 4: Unconjugated bilirubin

3: Conjugated bilirubin -Conjugated hyperbilirubinemia is caused by obstruction of the biliary ducts, as with gallstones or hepatocellular diseases such as cirrhosis or hepatitis.

The most common cause of liver inflammation is: 1: Tumor metastases to the liver 2: Wilson's disease 3: Hepatitis 4: Hemochromatosis

3: Hepatitis

A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of CSF c. the loss of autoregulatory control of ICP d. a normal balance between brain tissue, blood, and CSF

D. A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm Hg

Based on the pathophysiologic changes that occur as renal failure progresses, the nurse identifies the following indicators associated with the disease. Select all that apply. Hyperkalemia Metabolic alkalosis Anemia Hyperalbuminemia Hypocalcemia

Hyperkalemia Anemia Hypocalcemia

Based on her knowledge of the primary cause of end-stage renal disease, the nurse knows to assess the most important indicator. What is that indicator? Blood pressure Urine protein Serum glucose pH and HCO3

Serum glucose

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator? Serum calcium Serum lipase Serum bilirubin Serum amylase

Serum lipase

A major advantage of peritoneal dialysis is a. the diet is less restricted and dialysis can be performed at home b. the dialysate is biocompatible and causes no long-term consequences c. high glucose concentrations of the dialysate causes a reduction in appetite, promoting weight loss d. no medications are required because of the enhances efficiency of the peritoneal membrane in removing toxins

a

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching? a. "How did this happen? I've been faithful my entire marriage." b. "I'll wash my hands often." c. "I'll be very careful when preparing food for my family." d. "I'll take all my medications as ordered."

a

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia? a. Hypotension b. Polyuria c. Warm, moist skin d. Bradycardia

a

The dialysis solution is warmed before use in peritoneal dialysis primarily to a. encourage the removal of serum urea b. force potassium back into the cells c. add extra warmth to the body d. promote abdominal muscle relaxation

a

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highestnursing priority for this client? a. Assisting the client to turn, cough, and deep breathe every 2 hours b. Performing range-of-motion (ROM) leg exercises hourly while the client is awake c. Assisting the client to ambulate the evening of the operative day d. Teaching the client to choose low-fat foods from the menu

a

Which nursing action should be implemented in the care of a patient who is experiencing increased ICP? A. Monitor fluid and electrolyte status astutely. B. Position the patient in a high-Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion .D. Maintain physical restraints to prevent episodes of agitation.

a

A client with chronic renal failure is receiving hemodialysis three times a week. In order to protect the fistula, the nurse should a. take the BP in the arm with the fistula b. report the loss of a thrill or bruit on the arm with the fistula c. maintain a pressure dressing on the shunt d. start a second IV in the arm with the fistula

b

A patient with end-stage renal disease (ESRD) secondary to diabetes mellitus has arrived at the outpatient dialysis unit for hemodialysis. Which assessments should the nurse perform as a priority before, during, and after the treatment? a. Level of consciousness b. Blood pressure and fluid balance c. Temperature, heart rate, and blood pressure d. Assessment for signs and symptoms of infection

b

After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Elevate the patients arm above the level of the heart. b. Report the patients symptoms to the health care provider .c. Remind the patient about the need to take a daily low-dose aspirin tablet. d. Educate the patient about the normal vascular response after AVG insertion.

b

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurses teaching about management of CKD has been effective? a. I need to try to get more protein from dairy products. b. I will try to increase my intake of fruits and vegetables. c. I will measure my urinary output each day to help calculate the amount I can drink. d. I need to take the erythropoietin to boost my immune system and help prevent infection.

c

To assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should Select all that apply a. monitor the BP in the affected arm b. irrigate the graft daily with low-dose heparin c. palpate the area of the graft to feel a normal thrill d. listen with a stethoscope over the graft to detect a bruit e. frequently monitor the pulses and neurovascular status distal to the graft

c d e

The nurse is caring for a patient with chronic kidney disease after hemodialysis. Which patient care action should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? a. Assess the patient's access site for a thrill and bruit .b. Monitor for signs and symptoms of postdialysis bleeding. c. Check the patient's postdialysis blood pressure and weight. d. Instruct the patient to report signs of dialysis disequilibrium syndrome immediately.

c. Check the patient's postdialysis blood pressure and weight.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? a. Cure the cirrhosis b. Treat the esophageal varices c. Reduce fluid accumulation and venous pressure d. Promote optimal neurologic function

c. Reduce fluid accumulation and venous pressure

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: a. wear a gown when providing personal care for the client. b. place the client in a private room. c. wear a mask when handling the client's bedpan. d. wash her hands after touching the client.

d

A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is :a. pancreatitis b. hepatitis B c. hepatitis A d. acute cholecystitis

d

the nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

d

Nursing assessment for the patient receiving peritoneal dialysis would include which of the following to detect the most serious complication of this procedure? Palpate the abdominal wall for rebound tenderness. Inspect the catheter site for leakage of dialysate. Observe for evidence of bleeding. Measure fluid drainage to estimate incomplete recovery of fluid.

Palpate the abdominal wall for rebound tenderness.

When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions? a. Placing the patient in the prone position b. Frequent changes of positions c. Perform chest physiotherapy d. Suction the patient every 4 hours

b

Which should be included in the client's plan of care during dialysis therapy? a. limit the client's visitors b. monitor the client's blood pressure c. pad the side rails of the bed d. keep the client on NPO status

b

A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects? A. Urine output increases from 30 mL to 50 mL/hour .B. Blood pressure remains less than 150/90 mm Hg. C. The LOC improves. D. No crackles are auscultated in the lung fields.

c

Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the a. blood urea nitrogen (BUN) and creatinine. b. blood glucose level. c. patients bowel sounds. d. level of consciousness (LOC).

c

A community health nurse is caring for a client whose multiple health problems include chronic pancreatitis. During the most recent home visit, the nurse learns that the client is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action? Administer a PRN dose of pancreatic enzymes as prescribed. Teach the client about the importance of abstaining from alcohol. Arrange for the client to be transported to the hospital. Insert an NG tube, if available, and stay with the client.

Arrange for the client to be transported to the hospital.

Which condition is most likely to have a nursing diagnosis of fluid volume deficit? Appendicitis Pancreatitis Cholecystitis Gastric ulcer

Pancreatitis

skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that a. the patient will receive life-support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial activity c. the patient will be treated conservatively with close monitoring for changes in neurologic condition d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

d

A patient is admitted to the hospital with CKD. The nurse understands that this condition is characterized by a. progressive irreversible destruction of the kidneys b. a rapid decrease in urine output with an elevated BUN c. an increasing creatinine clearance with a decrease in urine output d. prostration, somnolence, and confusion with coma and imminent death

A

A client reporting shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor? Temperature Albumin Hemoglobin Bilirubin

Albumin

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF? Increased pH with decreased hydrogen ions Increased serum levels of potassium, magnesium, and calcium Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL Uric acid analysis 3.5 mg/dL and phenolsulfonphthalein (PSP) excretion 75%

Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL

You are alerted to a possible acute subdural hematoma in the patient who A. has a linear skull fracture crossing a major artery. B. has focal symptoms of brain damage with no recollection of a head injury .C. develops decreasing LOC and a headache within 48 hours of a head injury. D. has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC.

C

The nurse cares for a client after extensive abdominal surgery. The client develops an infection that is treated with IV gentamicin. After 4 days of treatment, the client develops oliguria, and laboratory results indicate azotemia. The client is diagnosed with acute tubular necrosis and transferred to the ICU. The client is hemodynamically stable. Which dialysis method would be most appropriate for the client? Hemodialysis Peritoneal dialysis Continuous arteriovenous hemofiltration (CAVH) Continuous venovenous hemofiltration (CVVH)

Hemodialysis

A patient undergoing a CT scan with contrast has a baseline creatinine level of 3 mg/dL, identifying this patient as at a high risk for developing kidney failure. What is the most effective intervention to reduce the risk of developing radiocontrast-induced nephropathy (CIN)? Performing the test without contrast Administering Garamycin (gentamicin) prophylactically Hydrating with saline intravenously before the test Administering sodium bicarbonate after the procedure

Hydrating with saline intravenously before the test

A home health nurse is caring for a client discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the client who has had pancreatic surgery? Proteinuria and hyperkalemia Hemorrhage and hypercalcemia Weight loss and hypoglycemia Malabsorption and hyperglycemia

Malabsorption and hyperglycemia

A nurse is performing an admission assessment of a client with a diagnosis of cirrhosis. What technique should the nurse use to palpate the client's liver? Place hand under the right lower abdominal quadrant and press down lightly with the other hand. Place the left hand over the abdomen and behind the left side at the 11th rib. Place hand under right lower rib cage and press down lightly with the other hand. Hold hand 90 degrees to right side of the abdomen and push down firmly.

Place hand under right lower rib cage and press down lightly with the other hand.

A client is scheduled for a CT scan of the abdomen with contrast. The client has a baseline creatinine level of 2.3 mg/dL (203 µmol/L). In preparing this client for the procedure, the nurse anticipates what orders? Monitor the client's electrolyte values every hour before the procedure. Preprocedure hydration and administration of acetylcysteine Hemodialysis immediately prior to the CT scan Obtain a creatinine clearance by collecting a 24-hour urine specimen.

Preprocedure hydration and administration of acetylcysteine

The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of mostconcern? The skin on the client's abdomen has multiple spider-shaped blood vessels. The client has gained 2 kg from the previous day. The client reports nausea and anorexia. The client's hands flap back and forth when the arms are extended.

The client's hands flap back and forth when the arms are extended.

The patient with CKD is receiving dialysis, and the nurse observes excoriations on the patient's skin. What pathophysiologic changes in CKD mostlikely occur that can contribute to this finding? Select all that apply a. dry skin b. sensory neuropathy c. vascular calcifications d. calcium-phosphate skin deposits e. uremic crystallization from high BUN

a b d

The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to a. obtain a specimen of the fluid and send for culture and sensitivity .b. take the patient's temperature to determine whether a fever is present. c. check the nasal drainage for glucose with a Dextrostik or Testape. d. have the patient to blow the nose and then check the nares for redness.

c. check the nasal drainage for glucose with a Dextrostik or Testape.

During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Obtain blood to check the blood urea nitrogen (BUN) level. c. Check the patients blood pressure. d. Give prescribed PRN antiemetic drugs.

c

During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do first? a. Administer hypertonic saline. b. Administer a blood transfusion. c. Decrease the rate of fluid removal. d. Administer antiemetic medications.

c

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate? a. high-carbohydrate, high-protein b. high-calcium, high-potassium, high-protein c. low-protein, low-sodium, low-potassium d. low-protein, high-potassium

c

A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority? a. Nausea b. Disturbed body image c. Anxiety d. Impaired nutrition: less than body requirements

d