Mod. 4 Practice Questions

A client with end-stage kidney disease has this serum lab analysis: K+ 5.9 mEq/L Na+ 152 mEq/L Creatinine 6.2 mg/dL BUN 60 mg/dL What is the priority nursing intervention? A. Assess heart rate and rhythm B. Implement seizure precautions C. Assess the client's respiratory status D. Evaluate the client's acid-base balance

A. Assess heart rate and rhythm

A student nurse is assigned a client with end-stage renal disease. Which of the following findings would the nurse NOT expect to see with this client? A. Hypokalemia B. Elevated phosphorus C. Metabolic acidosis D. Elevated BUN

A. Hypokalemia Hyperkalemia results from the decreased excretion of potassium by the kidneys, the breakdown of cellular protein, bleeding, and metabolic acidosis.

What would a nurse expect to see on assessment of a patient with acute kidney injury who has an arterial blood pH of 7.30? A. Rapid, deep respirations B. Hot, flushed face and neck C. Bounding peripheral pulses D. Persistent skin tenting

A. Rapid, deep respirations Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate CO2. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

How would you classify this burn? *picture of sunburn* A. Superficial partial thickness burn B. Full thickness burn C. Deep partial thickness burn D. Third degree

A. Superficial partial thickness burn Superficial/Partial thickness burns are typically red/pink and painful because it only affects the top layer and their nerve endings are still intact. Brisk cap refill will be present.

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1,875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? A. 635 mL/hr B. 938 mL/hr C. 1875 mL/hr D. 219 mL/hr

B. 938 mL/hr Half of the fluid replacement using the Parkland formula is administered in the first 8 hours, and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.

What is the definition of chronic kidney disease according to Kidney Disease Improving Global Outcomes definition? (GFR = Glomerular filtration rate) A. GFR < 60 mL/hr for less than 3 months B. GFR < 60 mL/min for more than 3 months C. GFR < 60 mL/min D. GFR > 60 mL/min

B. GFR < 60 mL/min for more than 3 months

The treatment of burns is related to the severity of the injury. The severity is determined by all of the following except ONE of the choices. Which one is NOT an indicator of the severity of the burn? A. Location of the burn B. The time of the day the burn occurred C. Extent of the burn based on total body surface area D. Patient risk factors (age, past medical hx) E. Depth of the burn

B. The time of the day the burn occurred

What is the purpose of using a tool like this Rule of Nines in burn assessments? A. To chart where the burns are located B. To determine the total body surface area (TBSA) affected by the burn C. To create a picture so the patient knows where the burns are located

B. To determine the total body surface area (TBSA) affected by the burn Two commonly used tools for determining the TBSA or the extent of a burn wound are the Lund-Browder Chart or the Rule of Nines.

A client is prescribed digoxin (Lanoxin) and furosemide (Lasix). It is most important for the nurse to assess which value before administering these medications? A. Serum sodium B. BUN C. Serum potassium D. Plasma B-natriuretic peptide

C. Serum potassium

A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? A. "Blood loss from burned tissue is most likely cause of hypovolemia." B. "Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia." C. "The usual cause of hypovolemia is evaporation of fluid from denuded body surfaces." D. "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

D. "Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

A 29-year-old male, David Rose, has sustained burns to the right arm, right leg, and perineum. Using the Rule of Nines, calculate total body surface area percentage that is burned. A. 25% B. 14.5% C. 33% D. 28%

D. 28% R arm = 4.5+4.5 = 9% R leg = 9+9 = 18% Perineum = 1% 9+18+1 = 28%

When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which finding is of most concern to the nurse? A. Serum K+ of 4.5 mEq/L B. Urine output of 35 mL/hr C. Decreased bowel sounds D. Blood pressure of 86/72 mm Hg

D. Blood pressure of 86/72 mm Hg Patient is at risk for hypovolemic shock, which hypotension is a sign of.

The nurse teaches a patient with CKD about prevention of complications. What should the nurse include in the teaching plan? A. Monitor for proteinuria daily with a urine dipstick B. Perform self-catheterization every 4 hours to measure urine C. Take calcium-based phosphate binders on an empty stomach D. Check weight daily and report a weight gain of greater than 4 pounds

D. Check weight daily and report a weight gain of greater than 4 pounds

In what phase of burn management is a patient with burns on 50% of her body in greatest risk of hypovolemic shock? A. Acute phase B. Rehabilitative phase C. Urgent phase D. Emergent phase

D. Emergent phase During the emergent phase, the greatest risk to the patient is hypovolemic shock.

The client is in the oliguric phase of AKI. For which risk should the nurse assess the client? A. Metabolic alkalosis B. Hypotension C. Hypokalemia D. Pulmonary edema

D. Pulmonary edema PE can develop during the oliguric phase of AKI because of decreased urine output and fluid retention. Metabolic acidosis develops because the kidneys cannot excrete hydrogen ions, and bicarb is used to buffer the hydrogen. HTN may develop as a result of fluid retention. Hyperkalemia develops as the kidneys lose the ability to excrete potassium.

The client with acute kidney injury has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of this client? A. Draw blood from the cannula for routine laboratory work. B. Percuss the cannula for bruits each shift. C. Inject heparin into the cannula each shift. D. Use the unaffected arm for blood pressure measurements.

D. Use the unaffected arm for blood pressure measurements. The external cannula must be handled carefully and protected from damage and disruption. The arm with the cannula is not used for blood pressure measurements, IV therapy, or venipuncture. Patency is assessed by auscultating for bruits each shift, not percussing. Heparin is not injected into the cannula.