MS 2 - Exam 3 Practice Questions: End of Neuro, Urinary, Renal
A client with nephrotic syndrome has developed anasarca. Which abnormally low laboratory value would indicate this assessment finding? 1. Cholesterol 2. Prothrombin time 3. Albumin 4. Calcium
Answer: 3. Explanation: When the glomeruli are damaged, the kidneys are excessively permeable to plasma protein, causing proteinuria and hypoalbuminemia. This leads to a decreased oncotic pressure, which results in anasarca.
What should the nurse include when prioritizing care for a client with polycystic kidney disease (PKD)? Select all that apply. 1. Pain management 2. Prevention of infection 3. Prevention of constipation 4. Monitoring of electrocardiogram (ECG) 5. Monitoring of electrolytes
Answer: 1, 2, 3. Explanation: Interventions for the client with PKD include pain management and prevention of infection, constipation, hypertension, and chronic kidney disease. Monitoring electrolytes is not necessary unless the disease progresses to kidney failure. If kidney failure is imminent, the client's ECG and electrolytes would be closely monitored.
The nurse is caring for a client with acute glomerulonephritis. Which signs and symptoms would the nurse anticipate? Select all that apply. 1. Fatigue 2. Periorbital edema 3. Thromboemboli 4. Cola-colored urine 5. Hypertension 6. Proteinuria
Answer: 1, 2, 4, 5, 6. Explanation: Fatigue, periorbital edema, hematuria (cola-colored urine), hypertension, and proteinuria are common manifestations of acute glomerulonephritis. Thromboemboli are common manifestations of nephrotic syndrome.
What is the most important information for the nurse to include when teaching a male client diagnosed with overflow incontinence? Select all that apply: 1. How to perform self-catheterization 2. The purpose of medication therapy 3. How to perform Kegel exercises 4. Elimination of caffeine in the diet 5. Increasing acidic fluids in daily diet
Answer: 1, 2. Explanation: Overflow incontinence occurs when the detrusor muscle fails to contract. The bladder becomes over distended. Causes for the underactive bladder may, or may not, be determined. An alpha adrenergic blocker medication may be used for male clients with an enlarged prostate to relax the muscle at the base of the urethra and allow urine to pass. Self catheterization may also be needed to empty the bladder. Kegel exercises are not utilized by men with this problem. Caffeine is not thought to be a cause of this condition and acidic fluids are not thought to be a cure.
A client receiving hemodialysis treatments arrives at the hospital with a blood pressure of 200/100 mmHg, a heart rate of 110 bpm, and a respiratory rate of 36 breaths/min. Oxygen saturation on room air is 89%. The client reports shortness of breath, and has + 2 pedal edema. The last hemodialysis treatment was yesterday. Which intervention should be done first? 1. Administer oxygen 2. Elevate the foot of the bed 3. Restrict the client's fluids 4. Prepare the client for hemodialysis
Answer: 1. Explanation: Airway and oxygenation are always the first priority. Because the client is reporting shortness of breath, and his oxygen saturation is only 89%, the nurse needs to try to increase the partial pressure of arterial oxygen by administering oxygen. The foot of the bed should not be elevated at this time as this may increase venous return to the heart and worsen pulmonary edema. The client is in pulmonary edema from fluid overload and will need to be dialyzed and have fluids restricted.
A client is experiencing hearing loss, buzzing, and ringing in the ears. Which type of brain tumor would the nurse suspect for a client with these symptoms? 1. Acoustic neuroma 2. Astrocytoma 3. Craniopharyngioma 4. Ependymoma
Answer: 1. Explanation: An acoustic neuroma is a benign tumor affecting the eighth cranial nerve. Symptoms include loss of hearing in one ear, buzzing or ringing in the ear, and occasionally some dizziness. The other tumors listed do not usually affect hearing.
An 80-year-old male client reports urinary retention. Which factor may contribute to this client's problem? 1. Benign prostatic hyperplasia (BPH) 2. Diabetes 3. Diet 4. Hypertension
Answer: 1. Explanation: BPH is common among older adult men, and typically results in urinary retention, frequency, dribbling, and difficulty starting the urine stream. Diabetes, diet, and hypertension usually do not affect urinary retention.
What would the nurse expect to assess in a client experiencing early symptoms of multiple sclerosis (MS)? 1. Diplopia 2. Grief 3. Paralysis 4. Dementia
Answer: 1. Explanation: Early symptoms of MS include slurred speech and diplopia. Grief isn't a clinical manifestation. Paralysis is a late symptom of MS. Although depression and a short attention span may occur, dementia is rarely associated with MS.
What is the best nursing intervention for a client who has just been diagnosed with a glioblastoma? 1. Providing honest, accurate information while maintaining hope 2. Discussing a referral to palliative care 3. Reviewing medication required to treat potential complications 4. Educating the client on the importance of receiving the influenza vaccine prior to initiating chemotherapy
Answer: 1. Explanation: It is most important for the nurse to provide honest and accurate information while maintaining hope. Glioblastoma are highly malignant tumors with a 50% mortality rate at one year. The other options are premature
A young client was recently diagnosed with multiple sclerosis (MS) and wants more information on the disease. Which statement is most accurate for the nurse to give? 1. MS is an autoimmune disease. 2. MS is more common in men than women. 3. MS is characterized by remyelination. 4. MS is an acute and curable disease.
Answer: 1. Explanation: MS is a chronic autoimmune disease that is more common in women than in men. It is characterized by multiple areas of demyelination and sclerosis of the underlying nerve fibers. There are no known cures for MS, although treatment can help promote remissions and prevent exacerbations.
The nurse is assessing a client who reports having pain during and after urination. The nurse suspects that this client may have a problem with the: 1. bladder. 2. kidneys. 3. ureters. 4. urethra
Answer: 1. Explanation: Pain during or after voiding indicates a bladder problem. Kidney and ureter pain would be in the flank area. Problems with the urethra would cause pain at the urinary meatus, and are commonly felt at the start of voiding.
Which client would be most at risk for secondary Parkinson's disease caused by pharmacotherapy? 1. A 30-year-old client with schizophrenia who is taking chlorpromazine 2. A 50-year-old client taking nitroglycerin tablets for angina 3. A 60-year-old client who is taking prednisone for chronic obstructive pulmonary disease 4. A 75-year-old client using naproxen for rheumatoid arthritis
Answer: 1. Explanation: Phenothiazines such as chlorpromazine deplete dopamine, which may lead to extrapyramidal effects. The other drugs don't place the client at a greater risk for developing Parkinson's disease.
When performing a physical assessment, the nurse discovers the client's urinary drainage bag lying on the bed. Based on this finding, the nurse identifies which problem as the priority? 1. Risk for infection 2. Reflex urinary incontinence 3. Risk for pain 4. Potential for ruptured bladder
Answer: 1. Explanation: Placing the drainage bag beside the client will allow the urine to flow back into the bladder, potentially causing an infection. This does not place the client at risk for incontinence or pain or a ruptured bladder.
The nurse is reviewing admission orders for a client with a diagnosis of pneumonia. The client has no known drug allergies. The client's laboratory results consist of blood urea nitrogen (BUN) 29 mg/dl, and creatinine 2.8 mg/dl. Which of the health care provider's orders would the nurse question? 1. Gentamicin 150 mg intravenous piggyback (IVPB) q24h 2. Doxycycline 100 mg IVPB q12h 3. Rocephin 1 g IVPB q24h 4. Zithromax 500 mg IVPB q24h
Answer: 1. Explanation: The aminoglycoside gentamicin may be nephrotoxic when administered to a client with altered renal function. This client's BUN and creatinine are elevated. The client is elderly, placing them at increased risk for the nephrotoxic effects of medications.
What is most important for the nurse to teach a client with urinary retentions about self-catheterization? 1. "You must keep the catheter clean as it is inserted." 2. "Catheterization is not something clients can perform alone." 3. "You will need to keep a catheter in at all times." 4. "The catheter is used to put fluid into the bladder."
Answer: 1. Explanation: The catheter must be kept clean as it is inserted. In an inpatient setting, nurses generally perform sterile catheterization. In the home setting the client utilizes clean technique. Clients can be taught to perform clean intermittent self-catheterization. The client does not have to keep the catheter in at all times. The catheter will not be used for irrigation as this is not an intervention for urine retention.
A client with a history of chronic renal failure missed a scheduled dialysis treatment, and is now being admitted to the hospital with pulmonary edema. The client's lab results include serum potassium 6.0 mEq/L (mmol/L), serum sodium 130 mEq/L (mmol/L), serum bicarbonate 18 mEq/L (mmol/L). What is this client's greatest risk? 1. Hypoxemia 2. Cardiac dysrhythmia 3. Fluid overload 4. Pericardial effusion
Answer: 1. Explanation: The client has developed pulmonary edema, which will decrease the client's air exchange. Airway and breathing are the priority. Elevated potassium can result in cardiac dysrhythmias. Fluid overload is possible due to missing a dialysis appointment. The client needs to be dialyzed as quickly as possible. Pericardial effusion occurs in advanced heart failure, pericarditis, metastatic carcinoma, cardiac surgery or trauma.
The nurse is caring for a client who is receiving hemodialysis hemodialysis treatments. Which intervention would be the most appropriate for this client? 1. Palpate for a thrill on the arm with the fistula 2. Palpate for a thrill on the arm without the fistula 3. Document the absence of a bruit as a normal finding 4. Take the blood pressure on the arm with the fistula
Answer: 1. Explanation: The nurse would palpate for a thrill, and auscultate for a bruit on the arm with the fistula. No procedures should be done on the arm with a fistula because it could damage the fistula. The absence of a thrill or bruit should be reported promptly to the health care provider because it indicates an occlusion and is not a normal finding.
A client reports a dry mouth two days after starting therapy with trihexyphenidyl for Parkinson's disease. What is the best action by the nurse? 1. Offer the client ice chips and frequent sips of water 2. Withhold the medication and notify the provider 3. Change the client's diet to clear liquid until the symptoms subside 4. Encourage the use of supplemental puddings and shakes to maintain weight
Answer: 1. Explanation: Trihexyphenidyl is an anticholinergic agent that causes blurred vision, dry mouth, constipation, and urinary retention. There is no need to withhold the drug unless hypotension or tachyarrhythmia occurs. A clear liquid diet isn't indicated at this time. It doesn't provide adequate nutrition, and may be more difficult to swallow than thickened liquids if dysphagia is present. Although weight loss may occur with Parkinson's disease, it is not a side effect of trihexyphenidyl
A client reports severe flank and abdominal pain. A flat plate of the abdomen shows urolithiasis. Which intervention does the nurse determine is appropriate? 1. Strain all urine 2. Limit fluid intake 3. Enforce strict bed rest 4. Encourage a high-calcium diet
Answer: 1. Explanation: Urine should be strained for calculi and sent to the laboratory for analysis. Fluid intake of 3 to 4 qt (3 to 4 L) per day is encouraged to flush the urinary tract, and prevent further calculi formation. Ambulation is encouraged to help pass the calculi through gravity. A low-calcium diet is recommended to help prevent the formation of calcium calculi
A nurse is teaching a client, who has Parkinson's disease, and his family about dietary practices. Which signs and symptoms are most important for the nurse to address? Select all that apply. 1. Fluid overload 2. Drooling 3. Aspiration 4. Choking 5. Dysphagia 6. Diarrhea
Answer: 2, 3, 4, 5. Explanation: Eating problems associated with Parkinson's disease include dysphagia, risk of choking, drooling, aspiration, and constipation. Fluid overload and diarrhea aren't problems specifically related to Parkinson's disease.
An older adult has developed a urinary tract infection, and is at risk for urosepsis. Which signs or symptoms should the nurse monitor? Select all that apply. 1. Decreased temperature 2. Increased heart rate 3. Decreased urinary output 4. Increased respiratory rate 5. Change in level of consciousness
Answer: 2, 3, 4, 5. Explanation: Symptoms of sepsis include low grade fever (in the older adult), rapid breathing, fast heart rate, weak pulse, profuse profuse sweating, unusual anxiety, changes in mental status or level of consciousness, and decreased, or absent, urinary output.
A client with acute renal failure has a serum potassium level of 7.0 mEq/L (mmol/L). What is the nurse's priority action for this client? 1. Urine specific gravity 2. Electrocardiogram (ECG) results 3. Mental status 4. Blood pressure
Answer: 2. Explanation: Acute renal failure can result in hyperkalemia, which can manifest in widening of the PR and QRS intervals on the ECG as well as irregular heartbeats, such as premature ventricular contractions. Urine specific gravity, mental status, and blood pressure are not a priority for this client.
A client is admitted for a cystoscopy with biopsy of the bladder. After obtaining the client's history, surgery was postponed. What would cause this surgery to be postponed? 1. The client stopped taking his anticoagulant three days ago. 2. The client has a urinary tract infection. 3. The client was previously been treated for carcinoma of the bladder. 4. The client took an antibiotic prior to the procedure.
Answer: 2. Explanation: Bladder biopsies should not be done when an active urinary tract infection is present because sepsis may result. Anticoagulants should be discontinued for three to five days before the procedure. The client who has been treated for bladder cancer may still require a biopsy to check effectiveness of treatment. Antibiotics are sometimes given prophylactically prior to the procedure.
Which instruction would help the client perform Kegel exercises? 1. Completely empty the bladder 2. Do the exercise 200 times per day 3. Sit or stand with your legs together 4. Drink small amounts of fluid frequently
Answer: 2. Explanation: Exercises begin with tightening and relaxing the vagina, rectum, and urethra two or three times a day. Depending on the strength of the pelvic musculature, anywhere from 10-30 repetitions can be done petitions during each session, and gradually increased. The client stops the flow of urine during urination to practice holding the flow. Standing or sitting with the legs apart will facilitate the exercises. Clients should drink 2-3L of fluids to prevent urinary problems.
A nurse is assigned four clients. Which client should the nurse see first? 1. A 17-year-old client 24 hours post appendectomy 2. A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome 3. A 50-year-old client three days post myocardial infarction 4. A 50-year-old client with diverticulitis
Answer: 2. Explanation: Guillain-Barré syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorders of airway, breathing, and then circulation seen first. There is no information to suggest that the client with post myocardial infarction has an arrhythmia or other complication. There is no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.
A client with bladder cancer has had his bladder removed, and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What is the nurse's conclusion? 1. The skin wasn't lubricated before the pouch was applied. 2. The pouch faceplate doesn't fit the stoma. 3. A skin barrier was applied properly. 4. Stoma dilation wasn't performed.
Answer: 2. Explanation: If the pouch faceplate doesn't fit properly, the skin around the stoma will be exposed to continuous urine flow from the stoma, causing excoriation, redness, weeping, and painful skin. A lubricant should not be used because it would prevent the pouch from adhering to the skin. When properly applied, a skin barrier prevents skin excoriation. Stoma dilation is not performed with an ileal conduit.
What information is important for the nurse to include when teaching a client with multiple sclerosis (MS) about ways to avoid exacerbation of the disease? 1. Patching the affected eye 2. Sleeping eight hours each night 3. Taking hot baths for relaxation 4. Drinking 1,500 to 2,000 ml of fluid daily
Answer: 2. Explanation: MS is exacerbated by exposure to may be found with trauma or subarachnoid hemorrhage. Increased glucose concentration is a non-specific finding indicating infection or subarachnoid hemorrhage.
A client with pneumonia requires mechanical ventilation, and is being transferred to the intensive care unit. Blood pressure is 70/40 mmHg, heart rate is 115 bpm, and respiratory rate is 32 breaths/min using accessory muscles. Intravenous fluids are infusing at 150 ml/hr. Urinary output has been 50 ml for the past four hours. This client is most at risk for: 1. postrenal failure. 2. prerenal failure. 3. intrarenal failure. 4. dehydration.
Answer: 2. Explanation: Prerenal refers to renal failure due to an interference with renal perfusion. Decreased cardiac output causes a decrease in renal perfusion, which leads to a lower glomerular filtration rate. There is no indication that this client has a problem that would indicate post renal failure or intrarenal failure. The infusion of fluid would prevent dehydration.
The nurse is assessing a client with Parkinson's disease and documents the following: "The client's face is expressionless, and the client's speech is monotone." How should the nurse interpret this? 1. The client is most likely depressed 2. These are common symptoms that produce an undesired façade of an alert and responsive individual. 3. The client's antipsychotic medication may need to be adjusted. 4. The client probably has dementia.
Answer: 2. Explanation: The nurse should recognize that these are common symptoms of Parkinson's disease. The symptoms do not indicate depression or dementia, although these are common in Parkinson's disease. Antipsychotic medication will often mimic Parkinson's disease extrapyramidal symptoms and is not indicated. Parkinson's disease is caused by degeneration of the substantia nigra in the basal ganglia of the brain, where dopamine is produced and stored. This degeneration results in motor dysfunction, resulting in symptoms such as an expressionless face and monotone speech.
A client has an indwelling urinary catheter. Urine is leaking from a hole in the collection bag. Which nursing intervention would be most appropriate? 1. Cover the hole with tape 2. Remove the catheter and insert a new one using sterile technique 3. Disconnect the drainage bag from the catheter and replace it with a new bag 4. Place a towel under the bag to prevent spillage of urine on the floor, which could cause the client to slip and fall
Answer: 2. Explanation: The system is no longer a closed system, and bacteria might have been introduced. A new sterile catheter should be inserted. Taping the hole and placing a towel under the bag leave the system open, which increases the risk of infection. Replacing the drainage bag by disconnecting the old one from the catheter opens up the entire system and increases the risk of infection. It is not recommended.
A client is diagnosed with chronic renal failure and is told to start hemodialysis. What is the priority teaching for the nurse to provide? 1. Follow a high-potassium diet 2. Strictly follow the hemodialysis schedule 3. There will be few changes in your lifestyle 4. Increase your fluid intake
Answer: 2. Explanation: To prevent life-threatening complications, the client must follow the dialysis schedule. The client should follow a low-potassium diet, because potassium levels increase in chronic renal failure. The client should know that hemodialysis is time-consuming and will cause a change in current lifestyle. The client does not need to increase fluid intake.
Which nursing intervention would be the most appropriate for a client with postoperative urinary retention? 1. Give a diuretic 2. Pour warm water over the perineum 3. Consider inserting a bladder catheter 4. Lay the client flat in bed
Answer: 2. Explanation: Urinary retention reflects bladder distention from urine. Sitting the client upright and pouring warm water over the perineum may help the client void. A diuretic is not necessary. If these measures aren't successful, the nurse should consider getting an order from the provider to insert a bladder catheter.
A nurse is evaluating a client to determine the extent of Parkinson's disease. Which symptoms would the nurse expect to see? Select all that apply. 1. Bulging eyeballs 2. Diminished distal sensation 3. Shuffling gait 4. Muscle rigidity 5. Changes in speech
Answer: 3, 4, 5. Explanation: Parkinson's disease is characterized by the slowing of voluntary muscle movement, muscular rigidity, and resting tremors. Clients with Parkinson's disease often have a distinctive shuffling gait. Clients may speak in a softened voice, often in monotone manner, and may slur or hesitate before speaking. Exophthalmos occurs in Graves' disease. Diminished distal sensation does not occur in Parkinson's disease.
A client is ordered diuretics. When should the nurse schedule this medication? 1. Anytime 2. Nighttime 3. Morning 4. Noon
Answer: 3. Explanation: A diuretic given in the morning has time to work throughout the day. Diuretics given at nighttime will cause the client to get up to go to the bathroom frequently, interrupting sleep
The nurse is providing instruction about skin care at the stoma site for a client with an ileal conduit. What is the most important information for this nurse to provide? 1. Change the appliance at bedtime 2. Leave the stoma open to air while changing the appliance 3. Clean the skin around the stoma with mild soap and water and dry it thoroughly 4. Cut the faceplate or wafer of the appliance no more than four mm larger than the stoma
Answer: 3. Explanation: Cleaning the skin around the stoma with mild soap and water and drying it thoroughly helps keep the area free of urine, which can irritate the skin. The appliance should be changed in the early morning when urine output is low to decrease the amount of urine in contact with the skin. The stoma should be covered with a gauze pad when changing the appliance to prevent urine from contacting the skin. The faceplate or wafer of the appliance should not be more than three mm larger than the stoma to reduce the skin area in contact with urine.
A client has just received a renal transplant, and has started cyclosporine therapy. What is the most important information for the nurse to share with this client? 1. "You may have a decreased appetite." 2. "Dizziness is common." 3. "Report any fever, a flushed feeling, or lethargy." 4. "Report any stomach discomfort or dyspepsia."
Answer: 3. Explanation: Fever, a flushed feeling, or lethargy suggest an infection. The nurse should closely monitor these symptoms in clients taking cyclosporine because it is an immunosuppressive drug. This medication should not cause decreased appetite, dizziness or stomach discomfort.
When teaching a client how to prevent recurrences of acute glomerulonephritis, which instruction should the nurse include? 1. Avoid physical activity 2. Strain all urine 3. Seek early treatment for respiratory infection 4. Monitor urine specific gravity every day
Answer: 3. Explanation: Hemolytic streptococci are common in throat infections and can cause an immune reaction that results in glomerular damage. This client should seek early treatment for a respiratory infection. Avoiding physical activity may promote urination but does not prevent recurrence of glomerulonephritis. Straining the urine helps identify renal calculi that have passed through the urine. Daily monitoring of urine specific gravity will help assess hydration status but does not aid in glomerulonephritis prevention.
When teaching a client about cystitis, a nurse explains that females are more prone to the disorder than males. Which factor explains a female's increased susceptibility? 1. Higher estrogen levels 2. Inadequate fluid intake 3. Urethral proximity to the rectum 4. Continuous nature of the mucosa
Answer: 3. Explanation: In females, the urethra and rectum are in close proximity, posing a greater risk for urethral contamination with feces after a bowel movement. Decreased estrogen levels may reduce vaginal and urethral lubrication, increasing the chance of irritation during coitus. Males and females can have equivalent fluid intake. The mucosa is continuous in both males and females.
Which assessment finding would the nurse expect as an early sign of myasthenia gravis? 1. Dysphagia 2. Fatigue that improves by the end of the day 3. Ptosis 4. Respiratory distress
Answer: 3. Explanation: Ptosis and diplopia are early signs of myasthenia gravis. Dysphagia and respiratory distress occur later. Symptoms are typically mild in the morning and may become exacerbated by stress or lack of rest.
Which symptom may indicate acute rejection of a transplanted kidney? 1. Increased urine output 2. Hypotension 3. Pain at the graft site 4. Decreased white blood cell (WBC) count
Answer: 3. Explanation: Signs and symptoms of acute rejection of a transplanted kidney include pain at the graft site, decreased urine output, hypertension, elevated WBC count, fever, and elevated creatinine level.
What is the best question a nurse can ask a client when determining the type of incontinence the client has developed? 1. "Do you drink alcohol daily? 2. "Do you have a busy job?" 3. "Are you incontinent when you cough or laugh? 4. "How old are you?"
Answer: 3. Explanation: Stress incontinence is the most common type of incontinence. The primary symptom is the loss of small amounts of urine when the client coughs, sneezes, jogs, or lifts. The person with stress incontinence cannot tighten their urethra enough to prevent leakage. The nurse should ask this question to determine if the incontinence occurs at these times. Alcohol, busy jobs and age are not significant risk factors. Stress incontinence can also occur after childbirth
A client who underwent a cystoscopy is scheduled to be discharged to home within 24 hours. What is the most important information for the nurse to give the client? 1. Expect bloody urine for about a week 2. Drink eight to ten glasses of water every eight hours 3. Try to urinate frequently and measure your output 4. Check the color, consistency, and amount of urine in the indwelling urinary catheter bag every four to eight hours
Answer: 3. Explanation: The bladder needs to be emptied frequently, and output should be measured to make sure the bladder is emptying. Blood in the urine is not normal except for small amounts for the first 24 hours following the procedure. Large amounts of fluids help flush microorganisms out of the body, but eight to ten glasses every eight hours may not be reasonable. This client may not have an indwelling urinary catheter.
A client has passed renal calculi. The nurse sends the specimen to the laboratory so it can be analyzed for: 1. antibodies. 2. type of infection. 3. composition of calculus. 4. size and number of calculi.
Answer: 3. Explanation: The calculus should be analyzed for composition to determine appropriate interventions such as dietary restrictions. Calculi do not result from infections. The size and number of calculi are not relevant. Calculi do not contain antibodies.
A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the clamp is opened to allow the dialysate to drain. The nurse notes 1,500 ml was instilled, but only 500 ml has drained. Which intervention should be done first? 1. Change the client's position 2. Call the health care provider 3. Assess the catheter for kinks or obstruction 4. Clamp the catheter and instill more dialysate at the next exchange time
Answer: 3. Explanation: The first intervention should be to check for kinks and obstructions because that could be preventing drainage. After checking for kinks, the client should change position to promote drainage. Don't give the next scheduled exchange until the dialysate is drained because abdominal distention will occur, unless the output is within the parameters set by the health care provider. If unable to get more output despite checking for kinks and changing the client's position, the nurse should then call the health care provider to determine another intervention.
A 75-year-old client is admitted with dehydration. The client's laboratory results are serum sodium 145 mEq/L, serum potassium 5.0 mEq/L, and serum creatinine 1.2 mg/dl and a BUN of 28 mg/dl. Based on these results, the nurse determines that the client is at risk for developing: 1. cancer. 2. urinary retention. 3. acute renal failure. 4. cardiac arrhythmias.
Answer: 3. Explanation: The laboratory results indicate an elevated serum blood urea nitrogen (normal ranges are from 10-20 mg/dl), which is reflective of dehydration. Volume depletion or dehydration is a risk factor for developing acute renal failure due to decreased perfusion of the kidneys. The serum potassium, sodium, and creatinine levels are within -normal range. A normal creatinine level and elevated BUN suggest intravascular fluid volume deficit.
A client is to undergo kidney transplantation with a living donor. What is the most important preoperative assessment by the nurse? 1. Urine output 2. Signs of graft rejection 3. Signs and symptoms of infection 4. Client's support system and understanding of lifestyle changes
Answer: 4. Explanation: A client undergoing renal transplantation will need vigilant follow-up care and must adhere to the medical regimen. The client is most likely anuric or oliguric preoperatively. Postoperatively this client will need to closely monitor urine output to make sure the transplanted kidney is functioning optimally. Rejection can occur postoperatively. Although the client will always need to be monitored for signs and symptoms of infection, it is a priority during the immediate postoperative period because of the initiation of immunosuppressive therapy.
A client received a transplanted kidney two months ago. He's admitted to the hospital with the diagnosis of acute rejection. Which assessment finding should the nurse anticipate? 1. Hypotension 2. Normal body temperature 3. Decreased white blood cell (WBC) counts 4. Elevated blood urea nitrogen (BUN) and creatinine levels
Answer: 4. Explanation: A client with acute renal graft rejection, will show evidence of deteriorating renal function. Elevated BUN and creatinine levels are expected. The client would most likely have acute hypertension. The nurse would see fever and elevated WBC counts because the body is recognizing the graft as foreign and is attempting to fight it.
A client has not voided for 10 hours following an inguinal hernia repair. What would the nurse consider as the cause of this problem? 1. Dehydration 2. History of smoking 3. Duration of surgery 4. Preoperative atropine
Answer: 4. Explanation: Anticholinergic medications, such as atropine, may cause urinary retention, particularly for the client who has surgery in the pelvic area. Dehydration, smoking, and duration of surgery are not risk factors for urinary retention. Opiate analgesics do pose some risk.
Before a renal biopsy, which information is most important to tell the health care provider? 1. The client signed a consent form. 2. The client understands the procedure. 3. The client has normal urinary elimination. 4. The client regularly regularly takes aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
Answer: 4. Explanation: Aspirin and NSAIDs can increase bleeding times, and commonly result in hemorrhaging when biopsies are performed. It is the health care provider's responsibility to make sure the client understands the procedure, which is needed for informed consent. It is not necessary to report that this client has normal urinary elimination.
A urine culture has been ordered for a male client. What information should the nurse teach the client? 1. Void in a clean container 2. Clean the foreskin of the penis if uncircumcised before specimen collection 3. Void into a urinal and then pour the urine into the specimen container 4. Begin the stream of urine in the toilet and catch the urine in a sterile container midstream
Answer: 4. Explanation: Catching urine midstream reduces the amount of contamination by microorganisms at the meatus. Voiding in a clean container is done for a random specimen, not a clean-catch specimen for urine culture. When cleaning an uncircumcised male, the foreskin should be retracted and the glans penis should be cleaned to prevent specimen contamination. Voiding in a urinal does not allow for an uncontaminated specimen because the urinal isn't sterile.
A client with chronic pyelonephritis is preparing to be discharged from the hospital. What is the most important information for the nurse to tell the client? 1. Stay on bed rest for up to two weeks 2. Use analgesia on a regular basis for up to six months 3. Have a urine culture every two weeks for up to six months 4. Antibiotic treatment may be needed for several weeks or months
Answer: 4. Explanation: Chronic pyelonephritis can be a long-term condition requiring antibiotic treatment for several weeks or months, as well as close monitoring to prevent permanent damage to the kidneys. Bed rest and analgesia may be used during the acute stage but usually are not required long-term. A urine culture is done two weeks after stopping antibiotics to make sure the infection has been eradicated.
What are the initial symptoms of Parkinson's disease? 1. Akinesia 2. Aspiration of food 3. Dementia 4. Pill rolling movements of the hand
Answer: 4. Explanation: Early symptoms of Parkinson's disease include coarse resting tremors of the fingers and thumb. Akinesia and aspiration are late signs of Parkinson's disease. Dementia occurs in only 20% of clients with Parkinson's disease.
A client with suspected myasthenia gravis is to undergo a test with edrophonium. The client asks if edrophonium can be used to treat myasthenia gravis. What is the nurse's best response? 1. It isn't available in an oral form 2. With repeated edrophonium use, immunosuppression may occur 3. Dry mouth and abdominal cramps may be intolerable adverse effects 4. The short half-life of edrophonium makes it impractical for long-term use
Answer: 4. Explanation: Edrophonium is not available in an oral form and the duration of action is 1 to 2 minutes, making it impractical for the long-term management of myasthenia gravis. Immunosuppression with repeated use is an adverse effect of steroid administration. Dry mouth and abdominal cramps are adverse effects of increased acetylcholine in the parasympathetic nervous system.
A client with multiple sclerosis (MS) is started on 20 mg of glatiramer subcutaneously daily. Immediately after the injection, the client experiences flushing and chest pain. What is the most appropriate nursing intervention? 1. Call a code 2. Call the provider to inform him of the client's adverse reaction 3. Administer oxygen 4. Monitor the client to see if the symptoms quickly dissipate
Answer: 4. Explanation: Glatiramer helps to decrease the number of relapses in the MS client. Flushing, chest pain, palpitations, anxiety, shortness of breath, and itching occur in some clients following administration of the medication. They typically are transient and self-limiting and don't need specific treatment.
The nurse is teaching a client newly diagnosed with myasthenia gravis about the cause of this disease. The nurse determines that teaching has been effective when the client states: 1. "It is a post-viral illness, characterized by ascending paralysis." 2. "It causes loss of the myelin sheath surrounding peripheral nerves." 3. "It results from the inability of basal ganglia to produce sufficient dopamine." 4. "It is the destruction of acetylcholine receptors that causes muscle weakness."
Answer: 4. Explanation: Myasthenia gravis, an autoimmune disorder, is caused by the destruction of acetylcholine receptors. Guillain-Barré syndrome is a post-viral illness characterized by ascending paralysis, multiple sclerosis is caused by loss of the myelin sheath, and Parkinson's disease is caused by the inability of basal ganglia to produce sufficient dopamine.
A client is admitted with a diagnosis of hydronephrosis secondary to calculi. The calculi have been removed, and post-obstructive diuresis is occurring. What is the nurse's most important intervention? 1. Take vital signs every eight hours 2. Weigh the client every other day 3. Assess the urine output every shift 4. Monitor the client's electrolyte levels
Answer: 4. Explanation: Post-obstructive diuresis, seen in hydronephrosis, can cause electrolyte imbalances. Laboratory values must be checked so electrolytes can be replaced as needed. Vital signs should initially be taken every 30 minutes for the first four hours and then every two hours. Urine output should be assessed hourly. The client's weight should be taken daily to closely monitor fluid status.
The nurse is obtaining a health history on a client. Which client statement indicates a risk of renal calculi? 1. "I've been drinking a lot of cola soft drinks lately." 2. "I've been jogging more than usual." 3. "I've had more stress since we adopted a child last year." 4. "I'm a vegetarian and eat cheese two or three times each day."
Answer: 4. Explanation: Renal calculi are commonly composed of calcium. Diets high in calcium may predispose a person to renal calculi. Milk and dairy are high in calcium. Soft drinks don't contain ingredients that would increase the risk of renal calculi. Jogging and increased stress are not considered risk factors for renal calculi formation.
What explanation, by the nurse, best describes the effect of plasmapheresis therapy for clients with myasthenia gravis? 1. It prevents exacerbation of myasthenia gravis when the client is pregnant or under stress. 2. It removes T and B lymphocytes that attack acetylcholine receptors. 3. It delivers acetylcholinesterase inhibitor directly into the bloodstream. 4. It separates and removes acetylcholine receptor antibodies from the blood.
Answer: 4. Explanation: The purpose of plasmapheresis in myasthenia gravis is to separate and remove circulating acetylcholine receptor antibodies from the blood of clients who do not respond to the usual therapies or who are in crisis. Although stress or pregnancy, may precipitate crisis, this is not the purpose of this procedure. Plasmapheresis does not remove T and B lymphocytes, nor does it deliver acetylcholinesterase inhibitor directly into the bloodstream.
A client presents with a possible urinary tract infection. Which urine characteristic should the nurse assess first? 1. Urine clarity 2. Urine specific gravity 3. Urine acetone 4. Urine protein
Answer: 1. Explanation: The nurse should first assess urine clarity. Cloudy urine usually indicates drainage, which may indicate an infection. Urine specific gravity provides information about fluid balance. Neither urine acetone nor urine protein indicates infection.
Which assessment findings demonstrate an effective outcome of levodopa-carbidopa medication therapy for a client with Parkinson's disease? Select all that apply. 1. Improved visual acuity 2. Decreased dyskinesia 3. Reduction in short-term memory 4. Reduced rigidity and tremor 5. Less frequent "freezing"
Answer: 2, 4. Explanation: Levodopa-carbidopa will increase the amount of dopamine in the central nervous system, allowing for more smooth and purposeful movements. The drug doesn't affect visual acuity, and should improve dyskinesia and short-term memory. It does not affect "freezing" or problems with autonomic functions, such as constipation, urinary problems, impotence, or pain.
Which antiparkinsonian drug can cause drug tolerance or toxicity if taken for too long? 1. Amantadine 2. Levodopa-carbidopa 3. Pergolide 4. Selegiline
Answer: 2. Explanation: Long-term therapy with levodopa-carbidopa can result in drug tolerance or toxicity manifested by confusion, hallucinations, or decreased drug effectiveness. The other drugs listed don't require the client to take a drug holiday.
A client admitted for acute pyelonephritis is about to start antibiotic therapy. Which symptom would the nurse expect this client to present? 1. Hypertension 2. Flank pain on the affected side 3. Bradycardia 4. Inability to walk
Answer: 2. Explanation: The client may report pain on the affected side because the kidney is enlarged and might have formed an abscess. Hypertension is associated with chronic pyelonephritis. The client would have tenderness with deep palpation over the costovertebral angle. Tachycardia would be expected with pain, not bradycardia. The client may have pain when walking, but should still be able to walk.
The nurse is providing discharge instructions for a client treated for acute pyelonephritis. What is the most important information for the nurse to include? 1. Avoid taking any dairy products 2. Return for follow-up urine cultures 3. Stop taking the prescribed antibiotics when the symptoms subside 4. Recurrence is unlikely because you've been treated with antibiotics
Answer: 2. Explanation: The client needs to return for follow-up urine cultures because bacteriuria may be present but asymptomatic. Intake of dairy products won't contribute to pyelonephritis. Antibiotics need to be taken for the full course of therapy regardless of symptoms. Pyelonephritis typically recurs as a relapse or new infection within two weeks of completing therapy.
The nurse is assessing a client with Parkinson's disease and documents the following: "The client's face is expressionless, and the client's speech is monotone." How should the nurse interpret this? 1. The client is most likely depressed 2. These are common symptoms that produce an undesired façade of an alert and responsive individual. 3. The client's antipsychotic medication may need to be adjusted. 4. The client probably has dementia.
Answer: 2. Explanation: The nurse should recognize that these are common symptoms of Parkinson's disease. The symptoms do not indicate depression or dementia, although these are common in Parkinson's disease. Antipsychotic medication will often mimic Parkinson's disease extrapyramidal symptoms and is not indicated. Parkinson's disease is caused by degeneration of the substantia nigra in the basal ganglia of the brain, where dopamine is produced and stored. This degeneration results in motor dysfunction, resulting in symptoms such as an expressionless face and monotone speech.
The nurse is assessing a client who has undergone a radical cystectomy and ileal conduit for the treatment of bladder cancer. Which finding would prompt the nurse to provide immediate intervention? 1. A red, moist stoma 2. A dusky colored stoma 3. Urine output more than 30 ml/hr 4. Slight bleeding from the stoma when changing the appliance
Answer: 2. Explanation: The stoma should be red and moist, indicating adequate blood flow. A dusky or cyanotic stoma indicates insufficient blood supply, and requires prompt intervention. Urine output less than 30 ml/hr, or no urine output for more than 15 minutes should be reported. Slight bleeding from the stoma when changing the appliance may occur because the intestinal mucosa is fragile.
One hour after receiving pyridostigmine bromide for myasthenia gravis, a client reports difficulty swallowing and excessive respiratory secretions. What medication would the nurse anticipate to reverse the effects of pyridostigmine bromide? 1. Additional pyridostigmine bromide 2. Atropine 3. Edrophonium 4. Acyclovir
Answer: 2. Explanation: These symptoms suggest cholinergic crisis or excessive acetylcholinesterase medication, typically appearing 45 to 60 minutes after the last dose of acetylcholinesterase inhibitor. Atropine, an anticholinergic drug, is used to antagonize acetylcholinesterase inhibitors. The other drugs are acetylcholinesterase inhibitors. Edrophonium is used for diagnosis, and pyridostigmine bromide is used to treat myasthenia gravis and would worsen these symptoms. Acyclovir is an antiviral and would not be used to treat these symptoms.
Which client does the nurse determine as being at greatest risk for developing acute renal failure? 1. A dialysis client who gets influenza 2. A teenager who has an appendectomy 3. A pregnant woman who has a fractured femur 4. A client with diabetes who has a heart catheterization
Answer: 4. Explanation: Clients with diabetes are prone to renal insufficiency and renal failure. The contrast used for heart catheterization must be eliminated by the kidneys, causing stress, and may produce acute renal failure. A dialysis client already has end-stage renal disease and would not develop acute renal failure. A teenager who has an appendectomy and a pregnant woman who fractures a femur are not at increased risk for renal failure.
A client, with viral meningitis, tells the nurse that he is upset because his primary health care provider will not give him an antibiotic for his meningitis. How should the nurse respond to his statement? 1. "You will be better in 2 to 3 days, so no antibiotic treatment is necessary." 2. "You could talk to the provider again and I will be an advocate for you." 3. "You only need medication if you develop some meningitis complications." 4. "Antibiotics are only effective for bacterial infections."
Answer: 4. Explanation: Clients with viral meningitis do not receive antibiotic treatment. Only clients with bacterial meningitis would receive antibiotic treatment. Clients with viral meningitis usually recover on their own in 7 to 10 days, and do not require antibiotic treatment.
18-year old college student presents to the ED with a severe headache and onset of bizarre behavior that started approximately five hours ago. Client is oriented to person, but not place or time. Physical assessment includes petechiae. Oral temperature is 104 F (40 C). HR: 128/bpm. RR: 24/min, O2: 95% on room air. Lumbar puncture ordered. Client is being evaluated for bacterial meningitis. What is the most important action by the nurse? 1. Prepare this client for endotracheal intubation 2. Administer the meningitis vaccination per order 3. Administer an analgesic per order 4. Obtaining IV access in preparation of antibiotic administration
Answer: 4. Explanation: This client's rapid course, and petechiae suggest that she is at risk for a fulminant presentation of meningitis, which can include circulatory collapse. Intravenous access may be needed, not only for immediate antibiotics to address the infection, but also for fluids and vasopressors. The client does not currently require intubation. Immunization will not prevent disease in persons who have already been exposed. An analgesic may be given, but IV access is the top priority.
