Week 11 Principals
A client with syndrome of inappropriate antidiuretic hormone presents with hyponatremia and fluid volume overload based on which of the following chemical responses? Answer Options * Increase in aldosterone Increase in vasopressin Decrease in brain natriuretic peptide Decrease in angiostensin II
Increase in vasopressin Principle: Antidiuretic hormone (vasopressin) promotes fluid reabsorption by the kidneys ; Page# 1552
IV dressing change
72 hrs
A client has a tumor that is pressing on the client's ureter. The nurse knows that this puts the client at risk for which of the following problems? Answer Options * Acute renal failure Urinary frequency Urinary hesitancy Bladder distention
Acute renal failure Principle: Urine flows from the collecting tubule of the nephron into the renal pelvis, ureters, bladder and then the urethra. ; Page# 1549
The nurse is caring for a client with a history of chronic urinary retention. The laboratory calls a creatinine level of 2.2 and potassium 6.8 mEq/L. The nurse should anticipate which of the following serious complications? Answer Options * Urinary tract infection Nephrolithiasis Acute renal failure Renal carcinoma
Acute renal failure Principle: Chronic urinary retention with large residual volumes could lead to azotemia and acute renal failure ; Page# 1571
The nurse is caring for a client who was recently diagnosed with cystitis and complains of urinary frequency. Which action by the nurse is most appropriate? Answer Options * Administer the antibiotic as prescribed Instruct the client on Kegel exercises Obtain an order for an antispasmodic Limit the amount of fluids after 6 pm
Administer the antibiotic as prescribed Principle: Pain to the suprapubic region along with urgency, odor, frequency and dysuria could suggest cystitis ; Page# 1622
Question Description The nurse is reflecting on her understanding of kidney physiology. Which of the following is an accurate statement about aldosterone? Answer Options * Aldosterone promotes sodium retention and potassium secretion Aldosterone promotes sodium secretion and potassium retention Aldosterone promotes sodium secretion and potassium secretion Aldosterone promotes sodium secretion and potassium secretion
Aldosterone promotes sodium retention and potassium secretion Principle: Aldosterone promotes sodium retention and potassium excretion ; Page# 1551
A client who had a left nephrostomy just returned to the unit. Which of the following assessment findings suggests a post operative complication? Answer Options * Blood pressure 82/48 mm/Hg Bloody urine collected from drainage bag Urinary output of 150 cc/ hour exceeding intake Decrease in pulse from 88 to 64 beats per minute
Blood pressure 82/48 mm/Hg Principle: Hemorrhage and shock are significant complications following renal surgery and the patient must be closely monitored ; Page# 1597
The laboratory department calls to report a calcium level of 6.8 mg/dL. Which of the following manifestations is consistent with this finding? Answer Options * Carpopedal spasms Increased lethargy Pupil dilation Dysphagia
Carpopedal spasms Principle: Chvostek’s and trousseau’s sign are classic signs of hypocalcemia ; Page# 1569
The nurse is reading a client's lab values and notes phosphorus levels trending upward. Which other finding should the nurse assess the client for? Answer Options * Chvostek sign Tall tented T waves Obtundation Hypernatremia
Chvostek sign Principle: When phosphorous levels rise the calcium level decreases and the patient may present with signs of hypocalcemia ; Page# 1572
Treatment of a client's urinary tract infection (UTI) includes a ten day administration of antibiotics. Which important teaching point should the nurse make when educating the client to reduce recurrence and drug resistance? Answer Options * Increase fluid intake of water to a minimum of 64 ounces each day. Stop the medication after bladder spasms and discomfort improves. Wipe from the front of the urinary meatus to the back after voiding. Finish all of the prescribed antibiotics even if you are feeling better.
Finish all of the prescribed antibiotics even if you are feeling better. Principle: Instruct patients to finish medications even if symptoms subside in order to reduce drug resistance ; Page# 1629
A client presents with an acute rejection of a liver transplant. The nurse expects which of the following treatments will be ordered? Answer Options * Provide oral antiretroviral therapy around the clock Initiate intravenous gamma globulin administration Remove the transplanted liver within 24 hours Increase the immunosuppressant medication
Increase the immunosuppressant medication Principle: Prepare for the removal of the transplanted organ in the setting of hyperacute rejection (pain over site, fever, swelling); acute rejections signal the need for an increase in immunosuppresants ; Page# 1607
A nurse is preparing a client who has received peritoneal dialysis for discharge. The nurse should give the highest priority to which of the following instructions? Answer Options * Maintain aseptic technique when caring for the catheter site Place drainage bag on the bed after the dwell time ends Warm dialysate in the microwave before starting peritoneal dialysis Avoid sexual intercourse during peritoneal dialysis
Maintain aseptic technique when caring for the catheter site Principle: Peritoneal dialysis uses the peritoneal membrane to remove waste products and excess fluid from the blood. ; Page# 1596
When caring for a client with a urostomy stoma, the nurse instructs the client to perform which of the following actions? Answer Options * Report any signs of redness to the stoma Cleanse the peristomal area with alcohol Remove the stoma wafer pad each night at bedtime Make sure the wafer fits closely around the stoma
Make sure the wafer fits closely around the stoma Principle: Cut or mold the stoma wafer so that it "hugs" the stoma ; Page# 639
Which of the following nursing interventions would the nurse implement when helping the client with bladder retraining? Select all that apply. Answer Options * Schedule set voiding times. Encourage increased fluid intake. Run tap water at the time voiding is attempted. Apply gentle pressure to lower abdomen. Administer loop diuretics.
Schedule set voiding times. Run tap water at the time voiding is attempted. Apply gentle pressure to lower abdomen. Principle: Retrain the bladder by providing a set amount of fluids, apply pressure over the bladder or run water to trigger micturation, straight catheter and record residual urine after the patient voids and discontinue residual checks when the amount is less than 100 ml ; Page# 1631
Diabetics
Should not receive Dextrose solutions
renal patients
Should not receive Lactate ringer solutions with K+
The nurse is caring for a client with benign prostatic hypertrophy (BPH). The nurse knows that classic signs of BPH include which of the following assessment findings? Select all that apply Answer Options * Urinary frequency Urgency Increased force of urinary stream Urinary dribbling Oliguria
Urinary frequency Urgency Urinary dribbling Principle: Clinical manifestations of benign prostatic hypertrophy include dribbling hesitancy, frequency, urgency, nocturia and a decrease in the force and volume of the urinary stream ; Page# 1762
Which of the following instructions should the nurse include when teaching a client on how to decrease the risk for urinary tract infections (UTI)? Select all that apply. Answer Options * Wipe front to back after voiding. Take daily bubble baths. Increase fluid intake. Void after sexual intercourse. Wait at least 6 hours between voids.
our Answer: Wipe front to back after voiding. Increase fluid intake. Void after sexual intercourse. Principle: Prevent urinary tract infections by encouraging showers, cleaning the peritoneum from front to back, increase fluids and avoid irritants, void frequently and after sexual intercourse ; Page# 1620
A client has been prescribed sildenafil citrate (Viagra) and discusses drug administration and safety to the nurse. Which statement by the client requires immediate intervention by the nurse? Answer Options * 'It is appropriate for me to take this mediation about 2 hours before intercourse.' 'It is not a problem if I take this medication with the pill I take for chest pain.' 'I will have to report to my physician any erection that last longer than 4 hours.' 'I will notify my health care provider if I get dizzy while taking this medication.'
'It is not a problem if I take this medication with the pill I take for chest pain.' Principle: Oral medications for erectile dysfunction (ending in afil, ex. tadalafil) should not be taken along with nitrates because of the risk for severe hypotension ; Page# 1757
A client who is scheduled for a total prostatectomy says to the nurse I am worried that I will be impotent following this procedure. Which statement by the nurse is appropriate? Answer Options * 'You will have to speak to the surgeon about your prostate concerns' 'There is a slight risk of impotence following a total prostatectomy' 'Urinary retention is usually the main risk after having this procedure' 'Erectile dysfunction will resolves in about a month following a total prostatectomy'
'There is a slight risk of impotence following a total prostatectomy' Principle: Due to the risk of pudendal nerve damage all prostatectomies carry a risk for impotence ; Page# 1772
A nurse is teaching a client who is currently undergoing peritoneal dialysis about nutritional intake. The nurse should include which of the following instructions in the teaching? Answer Options * 'The body will retain protein when you are receiving peritoneal dialysis.' 'Carbohydrates should be at least 65% of your caloric intake each day.' 'Carbohydrates should be at least 20% of your caloric intake each day.'
'You will have to increase you protein intake while on peritoneal dialysis.'
NG tube feeds
100 residual, hold fold
iv tubing changed every
24-72 HRs
A urinary test reveals that a client has glucose in the urine. The nurse knows that which of the following findings best explains this lab result? Answer Options * Consuming a high carbohydrate diet Recent antibiotic use for a urinary tract infection Drinking 12 ounces of orange soda prior to the test A 5 year history of diabetes mellitus
A 5 year history of diabetes mellitus Principle: Glucose is reabsorbed out of the urinary filtrate and returned to the bloodstream unless the amount in the bloodstream is elevated (Diabetes is the most common reason to have glycosuria) ; Page# 1549
The nurse receives report that a client was just admitted with prostatitis. Which of the following clinical manifestations is the nurse likely to observe? Select all that apply Answer Options * Temperature of 101.8 Dysuria Urgency Diffuse abdominal pain Scrotal edema
Answer Options * Temperature of 101.8 Dysuria Urgency Fever, dysuria, along with signs of urinary tract infection could suggest prostatitis ; Page# 1761
When caring for a client who has hypocalcemia, which of the following assessment findings require immediate attention from the nurse? Answer Options * Positive Trousseau or Chvostek's signs Increased blood pressure and heart rate Hyperglycemia and hyperkalemia Excessive salivation and halitosis
Answer: Positive Trousseau or Chvostek's signs Principle: Chvostek’s and trousseau’s sign are classic signs of hypocalcemia ; Page# 1569
The nurse is caring for a 26-year old male client with cystitis. Which of the following statements is true regarding cystitis? Answer Options * Cystitis could be caused by sexually transmitted diseases Cystitis effects more men than women in every age group Cystitis if advanced requires surgery and is painful Cystitis is most commonly linked to yeast infections
Cystitis could be caused by sexually transmitted diseases Principle: Cystits in the adult male is uncommon and could suggest a sexually transmitted illness ; Page# 1622
When caring for a client receiving peritoneal dialysis, which of the following nursing actions facilitates peritoneal drainage? Select all that apply. Answer Options * Reposition client to a side-lying position. Lower the head of bed. Place drainage bag below level of abdomen. Check for kinked or twisted tubing. Increase infusion amount.
Answer: Reposition client to a side-lying position. Place drainage bag below level of abdomen. Check for kinked or twisted tubing. Principle: Reposition the patient or raise the head of the bed to facilitate peritoneal drainage ; Page# 1599
The nurse is preparing to initiate the client's hemodialysis and notices absence of a bruit and thrill over the client's arteriovenous (AV) fistula. The nurse understands which of the following situations may have occurred? Answer Options * The AV fistula has ripened. The AV fistula is infected. The AV fistula is patent. The AV fistula has a blockage.
Answer: The AV fistula has a blockage. Principle: Report the absence of a bruit or thrill over the vascular access site since this could sugges a clot or blockage ; Page# 1597
When caring for a client with venous bleeding following a prostatectomy, the nurse should perform which of the following actions? Answer Options * Apply pressure over the bladder. Apply traction to the foley catheter. Check the client's creatinine level. Check the client's bladder capacity.
Apply traction to the foley catheter. Principle: Traction should be applied to the catheter if a venous bleed (darker and less viscous blood) is suspected following prostate surgery ; Page# 1774
The client with end stage renal disease (ESRD) asks the nurse why his doctor was talking so much about acid-base balance. Which of the following statements is correct? Answer Options * Acid base balance is only interrupted if the renin-angiotensin system is disrupted As kidney function declines the kidney loses its ability to maintain acid-base balance Acid base balance will only be effected in end stage renal disease, while fluid and electrolyte imbalances are early signs of ESRD ESRD will effect alkalotic clients but not acidotic clients
As kidney function declines the kidney loses its ability to maintain acid-base balance Principle: Chronic kidney disease progresses through 5 stages where the glomerular filtration rate steadily declines and the kidney loses its ability to maintain acid-base, fluid and electrolyte balance ; Page# 1569
Prior to initiating hemodialysis for a client with an arteriovenous (AV) fistula, the nurse checks patency of the fistula by which of the following nursing interventions? Select all that apply. Answer Options * Auscultate for bruit. Check venous blood return. Flush access site with 10 mL Normal Saline. Obtain blood pressure in arm with AV fistula. Palpate over AV fistula for thrill.
Auscultate for bruit. Palpate over AV fistula for thrill. Principle: Instruct that the arteriovenous fistula takes 2 - 3 months to ripen or mature before it can be used ; Page# 1594
A client with a history of diabetes mellitus is scheduled for a computerized tomography (CT). Upon arrival, the CT is rescheduled and the client is given instructions to hold the metformin 48 hours before and after the test. The client asks the nurse why won't the doctor allow me to have the CT done today. Which of the following statements made by the nurse is appropriate? Answer Options * Contrast medium could contribute to adverse effects from the metformin Your glucose level can not be too low or high when using the iodinated contrast material Taking the metformin could interfere with the accuracy of the test results so you have to hold it You could have a hypoglycemic reaction if you take the metformin prior to using contrast medium
Contrast medium could contribute to adverse effects from the metformin Principle: Metformin should be stopped 48 hours before and after the administration of iodinated contrast medium ; Page# 1474
The laboratory calls to report the client's calcium level is 5.4 mg/dL. The client reports numbness and tingling in the fingers and involuntary spasms. The nurse expects to administer which of the following medications? Answer Options * Kayexalate Naloxone Glucagon Calcium gluconate
Correct Answer: Calcium gluconate Principle: Calcium gluconate is given to reverse central nervous system depression caused by magnesium ; Page# 1568
A client with benign prostatic hyperplasia (BPH) is started on alfuzosin (Uroxatral). The nurse documents that the drug is effective based on which of the following findings? Answer Options * Decrease in urinary frequency Increase in nocturia Reduction in the prostate size Increase in urinary hesitancy
Decrease in urinary frequency Principle: Alpha-adrenergic blockers (end in -azosin, ex. doxazosin) relax the smooth muscle of the bladder neck and prostate which improves urinary flow ; Page# 1763
The laboratory calls to report a client's magnesium level is 4.1 mEq/L. Which of the following clinical manifestations are consistent with this finding? Select all that apply. Answer Options * Tachypnea Kussmaul respirations Decreased level of consciousness. Decreased deep tendon reflexes. Redness to the lower extremities.
Decreased level of consciousness. Decreased deep tendon reflexes. Redness to the lower extremities. Principle: Assess deep tendon reflexes and respirations with hypermagnesemia or when administering magnesium sulfate ; Page# 1569
A client has a reflexive contraction of the bladder. Which of the following conditions could cause this bladder abnormality?
Destruction of the spinal pathway from the brain to the bladder Principle: A reflexive contraction of the bladder can occur when the spinal pathway from the brain to the bladder is destroyed ; Page# 1621
The unlicensed assistive person reports to the nurse that a client who had prostate surgery 18 hours ago has pink tinged urine in the foley bag. Which of the following actions by the nurse is most appropriate? Answer Options * Obtain an order for a type and cross-match Document this finding in the client's chart Provide oxygen at 2 liters via nasal cannula Place the client in a modified Trendelenburg
Document this finding in the client's chart Principle: Drainage following protate surgery should appear light pink within 24 hours ; Page# 1773
While assessing the client's symphysis pubis, the nurse observes swelling and the client admits to tenderness upon palpation. Which action should the nurse take next? Answer Options * Obtain a rectal temperature Notify the rapid response team Encourage the client to void Perform a pain assessment
Encourage the client to void Principle: Swelling above the pubis could suggest an overdistended bladder ; Page# 1774
A client complains of discomfort following urodynamic testing. Which of the following treatments should the nurse anticipate performing to promote comfort? Answer Options * Elevating the legs Restricting fluids Giving a sitz baths Medicating with opioids
Giving a sitz baths Principle: Provide sitz baths to relieve discomfort associated from urodynamic testing ; Page# 1563
A client is receiving the initial dialysis treatment. During dialysis, the nurse knows that the client is at risk for disequilibrium syndrome and monitors the client for which of the following signs and symptoms?
Headache, seizures, and confusion Principle: Disequilibrium syndrome due to rapid removal of solutes during dialysis could cause headache, restlessness, decreased level of consciousness and seizures ; Page# 2597
The client with benign prostatic hypertrophy (BPH) returns from having a transurethral resection of the prostate (TURP). When planning the care for this client, the nurse knows that the client is most at risk for which of the following initial complications? Answer Options * Infection Thrombophlebitis Intestinal ileus Hemorrhage
Hemorrhage Principle: Avoid prolonged sitting, straining, lefting or sexual intercourse followiing prostate surgery to minimize pressure on the operative site ; Page# 1775
The nurse is caring for a client with diabetes mellitus who takes metformin (Glucophage) and insulin on a sliding scale. The client is scheduled for a computer tomography (CT) with iodinated contrast medium of the chest. Which of the following actions should the nurse give the highest priority? Answer Options * Obtain an order to give prn oxygen before and after the test Prepare to give a lower dose of insulin before and after the test Hold metformin (Glucophage) 48 hours before and after the test Review the client's liver function profile before and after the test
Hold metformin (Glucophage) 48 hours before and after the test
The nurse is caring for a client diagnosed with with glomerulonephritis. The nurse should monitor the client for which of the following complications? Answer Options * Respiratory acidosis Hypertensive encephalopathy Respiratory alkalosis Fatigue
Hypertensive encephalopathy Principle: Hypertensive encephalopathy resulting from acute glomerulonephritis is a medical emergency and measures to reduce blood pressure must be taken without worsening renal function! ; Page# 1571
A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before the next scheduled dialysis treatment, the nurse knows that the client is most at risk for which of the following imbalances? Answer Options * Hypophosphatemia Hypocalcemia Hyponatremia Hypokalemia
Hypocalcemia Principle: Classic signs of renal failure include anemia, hyperkalemia, hypoalbuminemia, hyperphosphatemia, hypocalcemia and metabolic acidosis ; Page# 1571
The lab calls to report that a client has a serum sodium of 155 mEq/L. Which of the following actions by the nurse is appropriate? Your Answer: Prepare to infuse a hypotonic solution
Principle: Prepare to infuse hypotonic intravenous fluids (0.45%) or isotonic fluids (0.9%), depending on the serum osmolarity, in the setting of hypernatremia ; Page# 259
When caring for clients with hypoparathyroidism, The nurse knows which of the following conditions leads to Trousseau' sign? Answer Options * Hypermagnesemia Hypophosphatemia Hypokalemia Hypocalcemia
Hypocalcemia Principle: Chvostek’s and trousseau’s sign are classic signs of hypocalcemia ; Page# 1569 Chvostek’s and trousseau’s sign are classic signs of hypocalcemia ; Page#
A client has been taking sildenafil (Viagra) 50 mg three times a week for 6 months. The client experiences an anginal attack and uses a nitroglycerin tablet (Nitrostat) that was prescribed for him before his Viagra prescription. The nurse knows that the drug to drug interaction puts the client at risk for which of the following complications? Answer Options * Hypoglycemia Hypotension Renal failure Liver failure
Hypotension Principle: Oral medications for erectile dysfunction (ending in afil, ex. tadalafil) should not be taken along with nitrates because of the risk for severe hypotension ; Page# 1757
A client presents with an ankle sprain with swelling and discomfort. The client states the discomfort is a 5 on a 0-to-10 scale. The nurse would expect treatment to include which of the following analgesics
Ibuprofen (Advil) Principle: Provide aspirin or acetaminophen (mild to moderate pain), non steroidal anti-inflammatory drugs (moderate pain) or morphine (severe pain) to manage pain ; Page# 232
The nurse is providing discharge teaching to an elderly male client treated for difficulty with urination. Which of the following responses by the client confirms his understanding of the prostate gland? Your Answer: Prostate gland enlargement is a normal part of the aging process
Principle: Prostate gland enlargement occurs as part of the aging process ; Page# 761
Question Description When caring for a client with an indwelling catheter, which nursing intervention would increase the risk for infection? Answer Options * Provide catheter care every 8 hours. Irrigate with sterile water each shift. Secure catheter to client's leg. Keep urine collection bag below the level of bladder.
Irrigate with sterile water each shift. Principle: Avoid routine catheter changes or irrigation to decrease risk for infection ; Page# 1628
A client had a transurethral resection of the prostate 18 hours ago and is currently on continuous bladder irrigation (CBI). Which assessment finding should the nurse act upon first? Answer Options * Irritability with dizziness Complaints of constipation Generalized weakness and fatigue since the surgery Urethral soreness with pink tinged urine in the irrigation bag
Irritability with dizziness Principle: Transurethral resection syndrome can occur following a transurethral resection of the prostate when the irrigation solution is absorbed and causes hyponatremia and hypovolemia. ; Page# 1771
When caring for a client with an order for an indwelling urinary catheter, the nurse knows that which of the following interventions decrease the client's risk for infection? Answer Options * Clean technique for catheter insertion. Keep urine collection bag at heart level. Irrigate catheter at least once a shift. Maintain a closed system.
Maintain a closed system. Principle: Maintain a closed system for indwelling urinary catheters to decrease the risk for infection ; Page# 1619
When caring for a client with renal failure, the nurse assesses the client for which of the following life-threatening complications? Answer Options * Metabolic acidosis Hypercalcemia Hypokalemia Polycythemia
Metabolic acidosis Principle: Bicarbonate is reabsorbed into the bloodstream and excess hydrogen ions are excreted into the urinary filtrate to maintain the acid-base balance ; Page# 1552
A client presents to the emergency department and complains of difficulty urinating for the past 18 hours. The client has a history of an enlarged prostate. After the insertion of a foley catheter, the nurse documents which of the following findings as normal? Answer Options * Mild hematuria Dark odorous urine Bladder distension Flank pain
Mild hematuria Principle: A bladder that's overdistended may stretch blood vessels in the prostatic capsule and lead to secondary hemorrhage ; Page# 1774
Due to the effects of aldosterone, the nurse performs which of the following interventions when caring for a client who has Addison's disease? Answer Options * Administer loop diuretics Monitor blood pressure Maintain a low sodium diet Assess neurological status every hour
Monitor blood pressure Principle: Aldosterone, angiotensin and antidiuretic hormone help to prevent lethal drops in perfusion pressure ; Page# 1551
Blood and parentral nutrition
Must have a 2way vu
The nurse is educating a client on how to best prevent sexually transmitted illnesses (STI). Which of the following statements by the client demonstrates an understanding of the single greatest risk for acquiring sexually transmitted diseases? Answer Options * My partner and I will commit to a monogamous relationship I will always make sure that a condom is used during sexual activity You should avoid having sex with individuals you don't know very well STI screening should be done routinely if you are sexually active
My partner and I will commit to a monogamous relationship Principle: The single greatest risk factor for acquiring a sexually transmitted disease is the number of sexual partners ; Page# 1755
chest tube
No more then 100 ml/ hr
When providing diet instruction to a client with kidney stones, which of the following oxalate-containing foods should the client avoid to help prevent recurrence? Select all that apply.
Peanuts Strawberries Spinach Principle: Prevent kidney stones by limiting sodium and protein intake, avoid oxalate containing foods (peanuts, strawberries, tea, spinach), drink fluids q 1-2 hours ; Page# 1632
The nurse is caring for a 53 year old female client who has a flaccid bladder and frequent urinary tract infections. Which of the following teachings is most important for the nurse to share with the client when educating about risk reduction strategies? Answer Options * Practicing Kegel exercises daily Urinating after sexual intercourse Performing the Crede's maneuver Wiping from the front to the back
Performing the Crede's maneuver Principle: Incomplete emptying of the bladder increases the risk for urinary tract infection ; Page# 1622
The nurse is caring for a client receiving peritoneal dialysis. The client admits to rebound tenderness and diffuse abdominal pain. The nurse should assess for which of the following complications? Answer Options * Fluid volume overload Cystitis Constipation Peritonitis
Peritonitis Principle: Peritonitis is the most common complication of peritoneal dialysis ; Page# 1596 Peritonitis is the most common complication of peritoneal dialysis ; Page#
The nurse is caring for a client with hypoparathyroidism. Which of the following assessment findings should the nurse expect? Answer Options * Positive Kernig's sign Positive McBurney's sign Positive Chvostek's sign Positive Tinnel's sign
Positive Chvostek's sign Principle: Chvostek’s and trousseau’s sign are classic signs of hypocalcemia ; Page# 1569
The nurse is assessing a client for urinary retention. Which of the following clinical manifestations is most consistent with urinary retention? Answer Options * Discomfort in the abdomen. Burning sensation while voiding. Post void residual measurement greater than 100 mL. Difficulty starting the urine stream.
Post void residual measurement greater than 100 mL. Principle: Check for residual urine (greater than 100 ml) after the patient voids (sign of retention) ; Page# 1629
The nurse is caring for a client who had a liver transplant. The nurse should give the highest priority to which goal? Answer Options * Maintain oxygen saturation over 90% Increase cerebral perfusion Understand risks for hyperglycemia Prevent any infection
Prevent any infection Principle: Infection is one of the leading causes of death following organ transplant ; Page# 1587 Infection is one of the leading causes of death following organ transplant ; Page#
A client presents to the emergency department and complaints of a large amount of blood in the stool for five days and lightheadedness. The client's blood pressure is 88/45 with a sustained heart rate of 135 bpm. When the lab calls to report the creatinine is elevated, the nurse suspects which of the following reasons for the acute renal failure? Correct Answer: Pre-renal failure
Principle: Hypoperfusion could lead to prerenal injury, damage to the renal parenchyma could lead to intrarenal injury and obstructions could lead to postrenal injury ; Page# 1571
A client who is scheduled for a magnetic resonance imaging (MRI) informs the nurse that he has a permanent pacemaker. Which action should the nurse take next? Your Answer: Call the physician and report the relevant finding quickly
Principle: MRIs are contraindicated for patients who have aneurysm clips, pacemakers, and internal defibrillators ; Page# 1555
The nurse is caring for a client admitted two hours previously with a complaint of abdominal pain? Which of the following assessment findings is consistent with septic shock from peritonitis? Your Answer: Fever and a white blood count of 18,000
Principle: Peritonitis causes a rigid board like abdomen with pain, fever and leukocytosis ; Page# 1607
A client with end stage renal failure is starting dialysis. When developing the plan of care, the nurse should consider which of the following risks? Select all that apply Correct Answer: Anemia Metabolic acidosis
Principle: The kidneys regulate red blood cell production, fluid, electrolyte and acid base-balance, excrete wastes, control blood pressure, and convert vitamin D to its active form. ; Page# 1549
When planning care for a dialysis client who receives metoprolol (Lopressor) 100 mg twice daily, the nurse knows the appropriate time to give the morning dose of the medication is which of the following? Your Answer: After the dialysis.
Principle: Withold antihypertensives prior to dialysis to reduce the risk for hypotension ; Page# 1599
Which of the following dietary restrictions does the nurse recommend to a client with chronic renal failure with a blood urea nitrogen (BUN) level of 62 mg/dL? Select all that apply. Answer Options * Protein Sodium Carbohydrates Potassium Calcium
Protein Sodium Potassium Principle: Restrict dietary protein when the blood urea nitrogen are elevated in the setting of renal insufficiency! ; Page# 1562
A client admits to taking aspirin several times a day to decrease the pain associated with Rheumatoid arthritis. The nurse knows that excessive use of this medication will increase the clients risk for: Answer Options * Hematuria Joint deformity Renal failure Hematoma
Renal failure Principle: The kidneys produce prostaglandin E which causes vasodilation and maintains renal blood flow (prolonged intake of prostaglandin inhibitors could impair renal function) ; Page# 1552
The nurse is caring for a client who is receiving dialysis. Due to an impaired metabolism of calcium and phosphorus, the nurse develops a plan of care to prevent which of the following complications? Answer Options * Renal osteodystrophy Disequilibrium syndrome Renal calculi Nephrotic syndrome
Renal osteodystrophy Principle: Osteodystrophy from elevated phosphorous and low serum calcium could result in the setting of end stage renal disease ; Page# 1595
The nurse is admitting a client diagnosed with end stage kidney disease (ESKD). The client has an arteriovenous graft. During assessment, the nurse notices a temperature of 101.4. Which action should the nurse perform next? Answer Options * Continue to monitor the client vital signs Encourage large amounts of fluid intake Report assessment finding to the physician Elevate the arm with the shunt on a pillow
Report assessment finding to the physician Principle: Arteriovenous grafts have a higher risk for thrombosis and infection ; Page# 1594
Which of the following nursing actions promote urinary continence in the incontinent client? Select all that apply. Answer Options * Scheduled voiding times. Pelvic floor strengthening exercises. Restrict fluid intake throughout the day. Voiding at a preset time schedule. Avoiding incontinence garments.
Scheduled voiding times. Pelvic floor strengthening exercises. Voiding at a preset time schedule. Principle: Teach kegel exercises, timed voiding, and bladder training to decrease urinary incontinence ; Page# 1624
A client has muscle twitching when the facial nerve is tapped. Which of the following findings should the nurse expect when reviewing the client's laboratory results? Answer Options * Increased urinary sodium Serum calcium, 6.0 mg/dL Blood glucose, 98 mg/dL Serum potassium, 2.8 mg/dL
Serum calcium, 6.0 mg/dL Principle: Chvostek’s and trousseau’s sign are classic signs of hypocalcemia ; Page# 1569 Chvostek’s and trousseau’s sign are classic signs of hypocalcemia ; Page#
heart failure (HF) or congestive heart failure (CHF)
Should not receive saline solutions
Hyponatremia less then 115
Signs: anorexia, muscles cramps, fatigue, symptoms and degree of speed
When caring for a client with severe renal failure and a 20 year history of hypertension, the nurse questions an order for which of the following? Answer Options * Metoprolol (Lopressor) Spironolactone (Aldactone) Bicarbonate administration Furosemide (Lasix)
Spironolactone (Aldactone) Principle: Potassium sparing diuretics should NEVER be used in the presence of renal injury ; Page# 1572
A client presents with a serum potassium of 7.2 mEq/L and is symptomatic. The nurse should anticipate taking which of the following orders from the primary care provider? Answer Options * Start the client on oral potassium supplements Encourage the client to eat a banana every day Administer a one time dose of glucagon, intramuscular Start an intravenous of dextrose and give insulin
Start an intravenous of dextrose and give insulin Principle: Reduce hyperkalemia with insulin, sodium bicarbonate, kayexalate, or diuretics ; Page# 1573
A client who had urosepsis is being discharged on ciprofloxacin (Cipro). Which of the following instructions should the nurse give to the client? Select all that apply. Answer Options * Take the medication with 8 ounces of water. Take at same time as vitamins/ mineral supplements. Report any pain or swelling of the extremities. Get as much exercise as possible. Breathlessness may occur at rest.
Take the medication with 8 ounces of water. Report any pain or swelling of the extremities. Principle: Flouroquinolones (end in -floxacin, ex. ciprofloxacin) are antibiotics that should be taken with 8 oz of fluid ; Page# 1619
A nurse is conducting a health fair to a group of clients who have end stage kidney disease (ESKD). Which of the following instructions has the highest priority? Answer Options * Take your blood pressure pills as prescribed Notify the health care provider with dysuria Change your position slowly when standing Wash your hands before eating any meals
Take your blood pressure pills as prescribed Principle: Cardiovascular disease is the leading cause of death for patients on dialysis ; Page# 1594
The nurse is completing a morning assessment on a client who is bedridden. Which of the following assessment findings suggest that the client has a full bladder? Answer Options * The bladder scan shows 150ml of urine The bladder is dull to percussion The client complains of flank pain The client complains of inguinal pain
The bladder is dull to percussion Principle: Percussion over the bladder (with urine) produces a dull note ; Page# 2555
The graduate nurse is treating a client who has acute renal failure. In reviewing the physiology of the kidney the graduate nurse recalls which of the following to be true? Answer Options * The glomerular membrane limits the passage of large substances including blood and albumin During glomerular filtration fluid from nephrons enter into the capillaries based on blood pressure When the kidneys fail the client is unable to produce any urine and will require dialysis The primary function of the kidney is to filter the blood coming from the inferior vena cava
The glomerular membrane limits the passage of large substances including blood and albumin Principle: The glomerular membrane allows for small particles to pass but limits larger substances like blood and albumin. ; Page# 1548
The nurse receives report on the following clients. Which client should the nurse see first? Answer Options * An older client with a glucose of 148 mg/dL A client who complains of testicular pain A client with a history of pneumonia An older client with urinary incontinence
The nurse receives report on the following clients. Which client should the nurse see first? Your Answer: A client who complains of testicular pain Principle: Testical torsion is a medical emergency and could resut in the loss of testicular function ; Page# 1779
When caring for a client with bacterial cystitis, the nurse encourages the client to increase their fluid intake of which of the following? Answer Options * Caffeinated tea Iced coffee Water Orange juice
Water Principle: Avoid urinary tract irritants (coffee, cola, alcohol, citrus, spices) with cystits ; Page# 1620
Question Description When caring for a client with benign prostatic hyperplasia (BPH), the nurse knows appropriate treatment for this condition includes which of the following medications? Answer Options * Angiotensin-converting enzyme inhibitors. Thiazide diuretics. 5 aplha-reductase inhibitors. Loop diuretics.
Your Answer: 5 aplha-reductase inhibitors. Principle: 5 Alpha-reductase inhibitor is a drug class that is used for benign prostatic hypertrophy, tablets that are crushed or broken should not be handled by pregnant women ; Page# 1762
Question Description The nurse is caring for a client who has a decrease in renal perfusion. Which of the following findings is likely to result from the kidney's initial compensatory mechanisms? Answer Options * An increase in blood pressure A decrease in the creatinine level An increase in urinary output A decrease in the urine specific gravity
Your Answer: An increase in blood pressure Principle: The R-A-A cascade (renin, angiotensin & aldosterone) is triggered by a decrease in renal perfusion which results in an increase in blood volume and pressure (increased in perfusion). ; Page# 1551
An elderly female client who was hospitalized for a total knee replacement develops functional incontinence. Which of the following statements by the client suggests a need for further teaching? Answer Options * Depending on the type of incontinence a person has, their maybe a medication to help Once I am independent with my transfers and ambulating I won't be incontinent anymore At some point just because I am older, I am likely to develop some type of incontinence Many people who have a total knee replacement are at risk for functional incontinence
Your Answer: At some point just because I am older, I am likely to develop some type of incontinence Principle: Incontinence is NOT a part of the aging process! ; Page# 1624
The nurse is caring for a client with a serum calcium of 6.2 mg/dL. The nurse should anticipate which of the following assessment findings?
Your Answer: Chvostek's sign Principle: Chvostek’s and trousseau’s sign are classic signs of hypocalcemia ; Page# 1569
When caring for a client on hemodialysis, the nurse knows which of the following actions removes the excess fluid and toxins from the blood? Answer Options * Gas exchange. Fluid shifts and third spacing. Osmosis and diffusion Hydrostatic pressure.
Your Answer: Osmosis and diffusion Principle: Hemodialysis is initiated to remove excess fluid and toxic nitrogenous wastes from the blood by osmosis and diffusion ; Page# 1573
The nurse has taught a client who has hypertension about foods that are low in sodium. Selection of which meal would indicate to the nurse that the client understands the dietary restrictions? Answer Options * Tossed salad, low-sodium dressing, bacon and tomato sandwich. New England clam chowder soup, no-salt crackers, fresh fruit salad. Skim milk, turkey salad, roll, and vanilla ice cream. Macaroni and cheese, diet Coke, a slice of cherry pie.
Your Answer: Skim milk, turkey salad, roll, and vanilla ice cream. Principle: Restrict sodium in the setting of edema, hypertension and heart failure ; Page# 1572
Classic signs of renal failure include
anemia, hyperkalemia, hypoalbuminemia, hyperphosphatemia, hypocalcemia and metabolic acidosis ; Chapter 13
