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The nurse would question an order for carbenicillin for a patient with a urinary infection if the patient is: (Select all that apply.)

b. allergic to penicillin. c. taking warfarin. d. taking oral contraceptives.

While the patient is on plasmapheresis, the nurse should monitor for: (Select all that apply.)

b. bleeding at the puncture site. c. a bruit at the shunt site. d. decreasing blood pressure. e. signs of hyperkalemia.

The nurse is collecting data from a patient who complains of having urinary frequency. When reviewing the patient's health history, the nurse would be prompted to inquire about the patient's intake of:

caffeine

A client who had a thrombotic stroke finished receiving intravenous rtPA therapy at 10:00 AM on Sunday. Sunday afternoon the physician writes an order to start Coumadin and Plavix that evening. The most appropriate action by the nurse would be to

call the physician and clarify when the medications should be given.

An 88yearold client has glomerulonephritis, is quite edematous, and has an order for large doses of diuretics. Before administering the first dose, the most appropriate action by the nurse would be to

call the physician to clarify the order.

The nurse monitoring a client load for risks of acute renal failure (ARF) understands that older clients are more susceptible to ARF because (Select all that apply)

cardiac contractile function and kidney perfusion diminish with age. of a higher probability of preexisting renal damage. older adults have more difficulty with fluid balance in general. the ability to retain sodium declines with age.

A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?

cardiac rhythm

A patient has experienced a subarachnoid hemorrhage and is at risk for increased intracranial pressure (ICP) due to the initiation of the vasodilatory cascade. The nurse plans care for this patient to avoid which primary initiating factor?

cerebral tissue ischemia

The nurse is conducting peritoneal dialysis for a client with renal failure and finds the drainage tubing has no outflow. The priority action that the nurse would take is to

check the tubing for kinks or obstruction.

A patients urine dipstick indicates a small amount of protein in the urine. The next action by the nurse should be to

check which medications the patient is currently taking.

The nurse clarifies that nephrotoxic drugs such as doxycycline and rifampin can cause kidney damage by:

chemical alterations of glomeruli.

Selfcare measures the nurse or speech therapist should teach the client who has residual dysphagia after a stroke include (Select all that apply)

chewing each bite thoroughly. placing foods in the unaffected side of the mouth. turning the head to the unaffected side and checking for retained food.

The nurse explains that polycystic kidney disease ultimately results in

chronic renal failure

A client is at a followup appointment and confesses that s/he does not take medications as prescribed. When planning a teaching strategy to address this problem, the nurse understands that clients often do not adhere to selfcare guidelines because (Select all that apply)

clients may believe they no longer need the medications. d. the economic costs are too high for them to absorb. side effects may be disruptive and unpleasant.

A client with ARF is allowed a specific amount of fluid by mouth during 24 hours in order to

compensate for insensible and measured fluid losses during the previous 24 hours.

In the nursing care plan for a client with acute pyelonephritis, the nurse would include teaching the client to

complete the entire course of antibiotics.

When doing an ophthalmologic examination the nurse practitioner assesses papilledema, which the practitioner recognizes as an indication of

compression of the second cranial nerve.

The nurse notes in the first few exchanges during peritoneal dialysis of a client that the effluent is tinged pink. The nurse's most appropriate action is to

continue the dialysis.

The nurse monitors for which assessment data in the patient diagnosed with a kidney infection?

costovertebral angle tenderness is present

A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin. What should the nurse monitor for adverse effects of the medication?

creatinine

The nurse reviewing laboratory reports on kidney function identifies a result that suggests decreased renal function, which is:

creatinine, 2.0 mg/dL.

When the patient asks why he has so many urinary tract infections (UTIs), the nurse points out that UTIs can result from:

bacteria that have colonized in the kidney.

When a 25-year-old woman comes to the emergency department with nonspecific urethritis, the nurse is prompted to inquire about the patients use of:

bath salts.

For a client with renal trauma exhibiting gross hematuria, the nurse would enforce the activity limitation of

bed rest.

The nurse explains to a client with chronic renal failure that the rationale for receiving calcium carbonate is that it

binds with phosphorus to eliminate it from the body.

A young adult employed as a hair stylist who has a 15 pack-year history of cigarette smoking arrives for an annual physical examination. Which area of increased risk should the nurse plan to teach the patient?

bladder cancer

What risks will the nurse plan to teach a 27-yr-old woman who smokes two packs of cigarettes daily?

bladder cancer

A 26-year-old patient who is employed as a hairdresser and has a 10 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for

bladder cancer.

After obtaining the health history for a 25-year-old who smokes two packs of cigarettes daily, the nurse will plan to do teaching about the increased risk for

bladder cancer.

For a client experiencing urinary retention with overflow, the factor in the client's history that would prompt the nurse to question an order for a cholinergic medication is

bladder outlet obstruction.

The nurse assessing a 50yearold woman who was involved in a car accident 2 hours ago finds marked tenderness and spasm in the suprapubic area and a nonpulsating mass. The nurse interprets these findings as indication of:

bladder trauma

The nurse assessing a 50-year-old woman who was involved in a car accident 2 hours ago finds marked tenderness and spasm in the suprapubic area and a nonpulsating mass. The nurse interprets these findings as indication of:

bladder trauma.

A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication?

bleeding

A new order for IV gentamicin (Garamycin) 60 mg BID is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patients

blood urea nitrogen (BUN) and creatinine.

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. What should the nurse assess before administering the medication?

bowel sounds

To best help the client who has the nursing diagnosis Ineffective Coping after a stroke, the nurse would

break a longterm goal into smaller pieces.

While participating in the creation of a teaching plan, the nurse suggests that a patient ingest cranberry juice every day to reduce the risk of developing a UTI. What information did the nurse use to make this suggestion? (Select all that apply.)

c. Compounds in cranberries inhibit the adherence of E. coli to the urogenital mucosa. d. Cranberries reduce the incidence of UTIs in patients after renal transplants. e. Cranberries contain a substance that prevents bacteria from sticking on the walls of the bladder.

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as

decorticate posturing.

The nurse encourages a stroke victim by telling them that following a cerebrovascular accident (CVA) caused by thrombosis, the client's condition may improve after several days as a result of

decrease of edema in the area.

When the patient enters into nephrotic syndrome after an exacerbation of glomerulonephritis, the nurse would expect to see:

decreased serum albumin

When the patient enters into nephrotic syndrome after an exacerbation of glomerulonephritis, the nurse would expect to see:

decreased serum albumin.

Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy?

decreased urine output

A patient is in the emergency department following a head injury. The nurse would assess for which sign indicating early increased intracranial pressure?

decreasing LOC

The nurse caring for a client in the diuretic phase of acute renal failure (ARF) should assess for manifestations of

dehydration

Following surgery for a pituitary tumor, when the client develops diabetes insipidus, the nurse explains that the drug that will be helpful to remedy the manifestations is

desmopressin

A client who has had intracranial surgery develops urine output in excess of 200 ml per hour. The nurse reports the findings, suspecting

diabetes insipidus

The patient had a carotid ultrasound that showed a 40% obstruction following a transient ischemic attack (TIA). The nurse anticipates that the treatment will consist of: (Select all that apply.)

diet modification. lifestyle alteration. aspirin for antiplatelet aggregation.

A client with nephrotic syndrome is being taught about selfcare at home. The teaching plan should include information on

diligent skin care.

A client is having intravesical BCG instillation for bladder cancer. Safety precautions the nurse should implement include

disinfect the toilet and urine containers with bleach.

Two days after surgery for an ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialist care for the stoma. The nurse identifies a nursing diagnosis of

disturbed body image related to change in body function.

The nurse explains that the serum creatinine level is a better indicator for renal disorders because serum creatinine

does not change in other systemic disorders.

A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it

is much less likely to clot.

When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find

judgment changes.

A client has been found to be an acceptable candidate for a kidney transplant. The nurse counsels the client and family that the client now faces the greatest impediment to renal transplantation,

lack of sufficient donor organs.

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required?

magnesium hydroxide

When a client has undergone a carotid endarterectomy and has been returned to the nursing unit with stable vital signs, the nurse should

maintain blood pressure within 20 mm Hg of the preoperative values.

A patient with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of

maintaining cardiac output.

A nurse teaches a community class about primary prevention for stroke, which includes (Select all that apply)

maintaining safe cholesterol levels. not smoking or smoking cessation. reducing heavy alcohol consumption.

The nurse informs the patient undergoing cystoscopy that following the procedure, the patient

may experience blood-tinged urine and urinary frequency.

Three days following intracranial surgery a client develops fever, nuchal rigidity, and headache. The nurse would suspect

meningitis

While caring for a client in the oliguric phase of ARF, the nurse's plan of care should include

meticulous skin care to prevent skin breakdown.

When planning teaching for a patient with benign nephrosclerosis the nurse should include instructions regarding

monitoring and recording blood pressure.

In the postprocedural nursing care of a client who has undergone a cystourethroscopy, the nurse would include

monitoring the client for manifestations of urinary tract infection

After an instillation of doxorubicin (Adriamycin) into the bladder for treatment of cancer in situ, the patient is then:

moved from side to side and from prone to supine.

The nurse uses a visual aid to demonstrate how a coupcontrecoup injures the brain by: (Select all that apply.)

moving forward to strike the anterior interior skull. striking the bony area opposite the site of impact.

The nursing action contraindicated in the care of a client with a severe basilar skull fracture is

nasal suctioning

The nurse explains that the nonurinary manifestations that frequently accompany urinary diseases are

nausea, vomiting, and anorexia.

A nurse could advise a group of employees at a worksite health fair that one health promotion measure that may help reduce the risk of renal cancer is

not smoking

In caring for a chronic dialysis patient with an arteriovenous fistula, the nurse would

not use the arm with the fistula when taking the client's BP.

During a client's first dialysis treatment, the client complains of a severe headache and appears somewhat confused. The priority action by the nurse's is to

notify the physician immediately.

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

o2 sat

While caring for a patient with an indwelling catheter, the nurse will include in the daily care the interventions of: (Select all that apply.)

observing tube placement and level of urine in collection bag. keeping the drainage bag below the level of the bed. cleaning the meatus and catheter with soap and water.

An 85yearold patient was held NPO since midnight last night for diagnostic testing. The procedure is now complete at 10:00 AM. The nurse should:

offer 4 ounces of water or juice every hour.

When the patient complains of urinary retention, the nurse can help the patient to void by: (Select all that apply.)

offering caffeine or carbonated drinks. providing a warm bath. instructing in the double void technique. running water in the lavatory to stimulate urination.

In a client with a history of frequent urinary tract infections (UTIs), the nurse would note the need for further teaching when the client says "I

often take baths instead of showers."

A client has an oral intake of 1500 ml and a urine output of 350 ml in a 24hour period. The nurse can correctly chart that the client is

oliguric

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include

oral administration of low dose aspirin therapy.

A patients renal calculus is analyzed as being very high in uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid eating

organ meats and sardines.

The nurse monitors for which characteristics of urine in the patient with suspected renal impairment? Select all that apply.

pH 3.0 Protein 10 mg/dL

The intraoperative nurse caring for a client having brain surgery to remove a tumor would be particularly careful about

padding and assessing the skin under the head frame.

When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about

pain with urination.

A 32-year-old female patient is diagnosed with uncomplicated cystitis. Which medications should the nurse expect to be prescribed for this patient? (Select all that apply.)

d. Nitrofurantoin (Macrodantin) e. Sulfamethoxazole and trimethoprim (Bactrim, Septra)

Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the

patients bowel sounds.

A nurse is caring for a client with chronic kidney disease who is admitted for pneumonia. The nurse would expect that an appropriate antibiotic that the physician might consider is a/an

penicillin

After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to

perform range-of-motion (ROM) exercises every 4 hours.

The nurse documents all the signs of epidural hematoma in a patient with a closed head injury, which are: (Select all that apply.)

periorbital ecchymosis. Battle's sign. nausea and vomiting.

During peritoneal dialysis the client's dialysate white blood cell count is 150/mm3 and neutrophils are 60%. This would indicate that the client has developed

peritonitis

To promote safety, when a client complains of the effects of diplopia after a stroke, the nurse would

place a patch over one eye

For a client who has just undergone cystourethroscopy with biopsy, the nurse should

plan care for a client having general anesthesia.

What laboratory value should the nurse check before administering captopril to a patient with stage 2 chronic kidney disease?

potassium

A 25-yr-old patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider?

potassium 6.5

A patient with hypertension and stage 2 chronic kidney disease (CKD) is receiving captopril (Capoten). Before administration of the medication, the nurse will check the patients

potassium.

A patient has a tumor in the cerebellum. What goal should the nurse use to focus the plan of care?

prevent falls

In the care plan for a client after nephrectomy, the nurse would include an intervention for

promoting effective breathing patterns.

A client experiencing hematuria tells the nurse that the bleeding occurs at the end of urination, which could indicate a lesion in the

prostate

A client with hydronephrosis has undergone stent placement to relieve the obstruction. The priority action of the nurse is to

provide accurate hourly fluid volume replacement.

A 25-year-old man comes to the college clinic with fever of 101 F and pain in the flank radiating into the thigh and genitals. He complains of nausea. The nurse recognizes these complaints as being indicative of:

pyelonephritis.

A 25yearold man comes to the college clinic with fever of 101° F and pain in the flank radiating into the thigh and genitals. He complains of nausea. The nurse recognizes these complaints as being indicative of:

pyelonephritis.

A patient with acute kidney injury (AKI) has an arterial blood pH of 7.30. The nurse will assess the patient for

rapid respirations.

Which assessment finding should the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30?

rapid, deep respirations (Kussmauls)

When obtaining the history of a client with acute glomerulonephritis, the nurse should be sure to ask about

recent respiratory tract infections.

When admitting a patient with acute glomerulonephritis, it is most important that the nurse ask the patient about

recent sore throat and fever.

The nurse assesses agnosia in a client who had a CVA. An example of this disturbance would be an inability to

recognize eating utensils

When the spouse of a client who has had a CVA as a result of a cerebral hemorrhage asks the nurse about the client's chances for recovery, the nurse should base a reply on knowledge that with this type of CVA

recovery is slow and less complete

The patient with brain tumor-related hydrocephalus is to have a ventriculoperitoneal (VP) shunt. The nurse explains that this surgical intervention will:

redirect the cerebrospinal fluid from the ventricles to the peritoneum.

The nurse performing intermittent peritoneal dialysis notes that the medical record shows the client has not had a bowel movement for 3 days. The nurse would be careful to assess the client for

reduced catheter outflow.

The nurse lists the functions of the kidney, which include: (Select all that apply.)

regulation of electrolytes. elimination of metabolic waste. regulation of fluid volume. regulation of blood pressure. secretion of erythropoietin.

The nurse warns a client with insulindependent diabetes mellitus (IDDM) who has developed proteinuria that this finding is significant because

renal failure will most likely develop in 5 to 10 years.

When a 90-year-old resident in a long-term care facility becomes progressively confused and irritable, the nurse should:

request an order for a urinalysis.

When a 90yearold resident in a longterm care facility becomes progressively confused and irritable, the nurse should:

request an order for a urinalysis.

Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction?

resp rate

The nurse understands that most often tumors occur in the bladder because the bladder wall is exposed most frequently to:

retained carcinogens.

The nurse who notes documentation of Grey Turner's sign in a client who experienced renal trauma would interpret this to be a manifestation of

retroperitoneal hemorrhage

During the review of the medications to be administered, the nurse notes that a patient has been prescribed liquid nitrofurantoin (Furadantin). The nurse will add an intervention to the nursing care plan to:

rinse the mouth after administration.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient?

risk for aspiration

The nurse is caring for a patient with an intracranial pressure monitoring device. What is the priority nursing diagnosis (NDX) for this patient?

risk for infection

A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of

risk for injury related to denial of deficits and impulsiveness.

To prevent recurrence of uric acid kidney stones, the nurse teaches the patient to avoid eating:

sardines and liver

The nurse cautions a young man who is taking ciprofloxacin (Cipro) for pyelonephritis to take all the prescription as directed in order to prevent recurrence, which can cause:

scarring of the renal pelvis.

The nurse cautions the diabetic patient that ultimately the disease will affect the blood flow through the kidney due to:

scleroses of renal vessels.

A client is being worked up for a possible brain tumor. An important intervention the nurse would include in the nursing care plan specific to this client is

seizure precautions

Which laboratory result should the nurse check before administering calcium carbonate to a patient with chronic kidney disease?

serum phosphate

Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check the laboratory value for

serum phosphate.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome?

short term memory

The nurse assisting with the oculovestibular response (OVR) test on a client recognizes that the brain stem is intact when the client's eyes

slowly move toward the ear irrigated with ice water.

A client had a kidney transplant and is doing well, except for being concerned that the spouse does not seem happy about it. The assessment by the nurse that would yield the most helpful information is to ask the

spouse what his/her role was while the client was ill.

When the client complains about having to perform quadricepsetting exercises, the nurse reminds him that the exercises will enhance ambulation by

strengthening the knee.

When a client is admitted to the hospital in an unconscious state following subarachnoid hemorrhage resulting from a ruptured intracranial aneurysm, the nurse anticipates that the manifestations that preceded the loss of consciousness were

sudden severe headache accompanied by vomiting

For a client with chronic renal failure who is experiencing insomnia, the least helpful strategy would be

taking an overthecounter sedative drug.

The nursing action that would be appropriate in caring for a client who has experienced stroke because of hemorrhage is to

teach the client to avoid the Valsalva maneuver.

A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should

teach the family that emotional outbursts are common after strokes.

The health care provider orders a clean-catch urine specimen for culture and sensitivity testing for a patient with a suspected urinary tract infection (UTI). To obtain the specimen, the nurse will plan to

teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup.

A patient with bladder cancer is scheduled for intravesical chemotherapy. In preparation for the treatment the nurse will teach the patient about

the need to empty the bladder before treatment.

Health promotion measures the nurse could suggest to clients to prevent renal artery disease are

the same as those for cardiovascular disease.

The nurse explains to the client that the glucosuria in the urinalysis indicates that

the serum glucose level is above the renal threshold.

The nurse teaching a client about continuous ambulatory peritoneal dialysis (CAPD) would include the information that

there are four daily cycles with an 8hour dwell for one cycle during the night.

The nurse describes a concussion as a closed head injury in which:

there is amnesia related to the incident.

A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for

tissue plasminogen activator (tPA) infusion.

The assessment of a patient's ability to think can be evaluated by asking the patient:

to add three numbers together in his head.

The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient

to call the health care provider if stools are tarry.

If the client has adequate proprioception, the nurse would know that the client can

touch nose with eyes closed.

The nurse would explain to a client scheduled for an electroencephalogram (EEG) that an EEG

traces superficial electrical activity of the cerebral cortex.

When turning the patient who is in Crutchfield tongs traction, the nurse will:

turn the patient as a unit by log rolling.

Safety precautions the nurse instructs the client with homonymous hemianopsia to use include

turning the head to scan the visual field.

The nurse caring for a patient with an epidural hematoma suspects diabetes insipidus when the patient exhibits increased:

urinary output.

The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider?

urine output

The nurse caring for a man with a megaureter should assess for the potential problem of

urine reflux

For the nurse trying to assist a client with renal failure to stay within the prescribed fluid restriction, the least helpful strategy would be to

use ice chips liberally instead of fluids.

The critical care nurse explains to the family of a client who is to receive nimodipine following hemorrhagic stroke that the purpose of this drug is to treat

vasospasm

A week after a client experienced a ruptured cerebral aneurysm, he becomes extremely indecisive and has frequent episodes of incontinence. The nurse reports these events as probable

vasospasm.

During change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipate?

visual deficits

The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have

visual deficits.

To help the peritoneal dialysis client who is complaining of low back pain associated with increased weight in the abdomen, the nurse would suggest

walking on surfaces with gradual inclines.

The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what?

wash hands

The client with chronic renal failure who would not be a candidate for peritoneal dialysis is a client

with severe respiratory disease

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for related functional deficits?

"Are you experiencing vision problems?"

A client has been on dialysis for 6 weeks. The family is complaining that instead of feeling grateful at this second chance at life, the client has become irritable with them and seems depressed. The most helpful response by the nurse would be

"Depression is very common at this time; it is hard to adapt to the losses s/he feels."

Which question should the nurse ask to assess a patient's dysuria?

"Do you have pain when you urinate?"

When a client tells the nurse that she recently began experiencing urgency and frequency, the appropriate question for the nurse to ask as part of the psychosocial history is

"Have you been experiencing any anxiety?"

To determine if a client has an initial manifestation typically seen in clients with bladder neoplasm, the nurse would ask

"Have you noticed any blood in your urine?"

A patient with a history of hypertension is diagnosed with chronic kidney disease. When the patient asks the nurse how this occurred, which response by the nurse is the best?

"High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis."

Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse?

"I am going to drive home and go right to bed."

Which confidence shared by a female client would alter the decision to use magnetic resonance imaging (MRI) as a diagnostic modality?

"I didn't tell my doctor that I've had my stomach stapled."

Which statement by the patient being discharged after hospitalization for urolithiasis indicates the need for further teaching."

"I should increase sodium in my diet to increase urine output."

The home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying. Which patient statement indicates that the teaching has been effective?

"I will clean the catheter carefully before and after each catheterization."

Which statement by a 22-yr-old female patient with cystitis indicates to the nurse that instruction regarding prevention of future urinary tract infections (UTIs) has been effective?

"I will empty my bladder every 3 to 4 hours during the day."

Which statement by the patient with PKD indicates the need for further teaching?

"I will have prunes for breakfast each day."

Which statement by the patient being discharged after treatment for acute glomerulonephritis indicates the need for further teaching?

"I will increase the protein in my diet to help me heal."

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective?

"I will measure my output each day to help calculate the amount I can drink."

In reviewing teaching with a patient being treated with antibiotics and Pyridium for a urinary tract infection (UTI), which patient statement indicates the need for further teaching?

"I will report if my urine is orange or red in color.

Which statement by the female patient about the collection of a clean-catch urine sample indicates the need for further teaching?

"I will spread my labia and wipe from back to front with the towelette."

Which statement by a patient with interstitial cystitis indicates to the nurse that further instruction is needed?

"I will start taking high potency multiple vitamins every morning."

Which statement by the patient diagnosed with pyelonephritis indicates a need for further teaching?

"I will take my entire course of phenazopyridine to treat future UTIs."

The nurse evaluates a need for further instruction about a sodiumrestricted diet when the patient with glomerulonephritis says:

"I'm glad I can still drink carbonated drinks."

Plasmapheresis has been ordered for the patient diagnosed with glomerulonephritis. Before the procedure, the patient correctly reports that the procedure will help her when she states that it will:

"Identify specific organisms causing my disease."

The nurse provides education for a patient who is experiencing urinary incontinence. Which statement by the patient indicates the need for further education?

"Incontinence is normal with aging."

The nurse is providing care to a patient who states, "My doctor says I am experiencing nocturia. What does that mean?" Which response by the nurse is best?

"It means you are getting up frequently at night to urinate."

urinary retention. What does that mean?" Which response by the nurse is best?

"It means you are unable to completely empty your bladder."

The nurse is providing care to a patient who states, "My doctor says I am experiencing renal colic. What does that mean?" Which response by the nurse is best?

"It means you have pain radiating to your groin."

The nurse is providing care to a patient who states, "My doctor says I am experiencing urinary urgency. What does that mean?" Which response by the nurse is best?

"It means you have the sudden urge to void immediately."

Which statement by the 65-year-old female patient about age-related changes to urinary function indicates the need for further teaching?

"My risk of urinary infections decreases as I age because of the changes in vaginal pH."

Which statement by a patient who had a cystoscopy the previous day should the nurse report immediately to the health care provider?

"My temperature is 101."

Which statement by the patient recently diagnosed with a meningioma indicates understanding of the diagnosis?

"My tumor can be removed, but I can still have damage because of pressure in my brain."

A 74-yr-old patient who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis?" Which initial response by the nurse is best?

"Tell me more about what you are thinking regarding dialysis."

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation?

"The monitoring system helps show whether blood flow to the brain is adequate."

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?

"The obstructing plaque is surgically removed from inside an artery in the neck."

In providing an educational inservice to the nursing staff about peritoneal dialysis, which information does the nurse include in this presentation?

"The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis.

The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). The family asks the nurse why their father had a seizure. What is the best response by the nurse?

"The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain."

A patient is scheduled to have a cystometrography performed. Which statement by the patient indicates an understanding of the planned test?

"The test will measure my urine flow volume and muscle function."

The nurse is caring for a patient who is pale and experiencing fatigue secondary to anemia related to chronic kidney disease. When the patient's spouse asks why the patient is anemic, what response by the nurse is the best?

"There is a decreased production by the kidneys of the hormone erythropoietin, which is the cause of anemia."

Which statement by the patient diagnosed with chronic kidney disease who is prescribed furosemide (Lasix) indicates that teaching about this medication was effective?

"This pill will reduce the swelling in my body and get rid of the extra potassium."

The nurse asking a client questions that test orientation would include

"What year is this?"

A client has renal cancer and is scheduled for a nephrectomy. Preoperatively, the nurse finds the client very quiet with a worried facial expression. Which statement by the nurse would be most appropriate?

"You look concerned. Are you worried about having only one kidney?"

The nurse provides care for the patient diagnosed with a kidney stone that has not passed. What statement is most important to include in the teaching for this patient?

"You must strain all urine to confirm whether or not the stone has passed."

The patient scheduled for a PET (positron emission tomography) scan of the brain asks if there is any special preparation for the test. The nurse correctly responds with which statements? (Select all that apply.)

"You should avoid any tranquilizers or sedatives the night before and the day of the test." "You will need to sign a consent form for this test to be performed." "You will have an IV inserted for the exam."

In providing education to a patient diagnosed with renal carcinoma, the patient states, "My doctor says I am a stage I. What does that mean?" Which response by the nurse is best?

"Your cancer is limited to the renal capsule."

The nurse is caring for a patient admitted with a diagnosis of acute kidney injury. The patient asks the nurse, "Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is the most appropriate?

"Your condition can be reversed with prompt treatment and usually will not destroy the kidney."

A patient passing bloody urine has scheduled a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate?

"Your doctor will insert a lighted tube in the bladder through your urethra, inspect the bladder, and instill dye to outline your bladder on x-ray."

A patient has been diagnosed with a pituitary adenoma. Which assessment finding supports that it is a nonfunctioning form?

. 20/60 vision using a Snellen chart

A patient has had a surgical resection of an acoustic neuroma. The nurse would prioritize which postoperative assessment?

. Identifying damage to cranial nerves VII, IX, X, and XII

A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? Put a comma and space between each answer choice (a, b, c, d, etc.) C, D, A, B

. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

The nurse is caring for a patient who has just returned to the post-surgical unit following renal surgery. When assessing the patients output from surgical drains, the nurse should assess what parameters? Select all that apply.

A) Quantity of output B) Color of the output C) Visible characteristics of the output

The nurse is preparing to collect an ordered urine sample for urinalysis. The nurse should be aware that this test will include what assessment parameters? Select all that apply.

A) Specific gravity of the patients urine B) Testing for the presence of glucose in the patients urine C) Microscopic examination of urine sediment for RBCs D) Microscopic examination of urine sediment for casts

A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patients peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply.

A) The cuffs are made of Dacron polyester. B) The cuffs stabilize the catheter. C) The cuffs prevent the dialysate from leaking. D) The cuffs provide a barrier against microorganisms.

A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes?

A. fib

What should the nurse include in a focused assessment of a patient's left posterior temporal lobe functions?

Ability to understand written and oral language

The critical care nurse is monitoring the patients urine output and drains following renal surgery. What should the nurse promptly report to the physician?

Absence of drain output

A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient?

Absolute bed rest in a quiet, nonstimulating environment

A patient in a barbiturate coma for increased intracranial pressure (ICP) has audible gurgling through the endotracheal tube. What should the nurse do first before suctioning this patient?

Administer 100% oxygen.

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first?

Administer 5% hypertonic saline intravenously.

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now reporting a headache. Which prescribed intervention should the nurse implement first?

Administer IV 5% hypertonic saline.

Paramedics have brought an intubated patient to the ED following a head injury due to acceleration- deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?

Administer benzodiazepines on a PRN basis.

A patient with chronic kidney disease is experiencing manifestations of anemia. Based on this data, which treatment does the nurse anticipate for this patient?

Administer erythropoietin (Epoetin) injections.

A patient with renal calculi is hospitalized with gross hematuria and severe colicky left flank pain. Which nursing action will be of highest priority at this time?

Administer prescribed analgesics.

Which nursing action is of highest priority for a patient with kidney stones who is being admitted to the hospital with gross hematuria and severe colicky left flank pain?

Administer prescribed analgesics.

Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN?

Administer the prescribed clopidogrel (Plavix).

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?

Administer the prescribed short-acting insulin.

The nurse is caring for a patient scheduled for renal angiography following a motor vehicle accident. What patient preparation should the nurse most likely provide before this test?

Administration of a laxative

A patient with an ischemic stroke is being considered for recombinant tissue plasminogen activator (rt-PA). The nurse recognizes which factors as a contraindication to this treatment? Select all that apply.

Age 83 years 10 year history with type 2 DM takes warfarin for a fib

A patient is being discharged after treatment for an ischemic stroke. Which medications does the nurse correlate with this management of this neurological disorder? Select all that apply.

Anticoagulants Antihypertensives Antiplatelet therapy Lipid-lowering agent

The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply.

B) Apnea C) Coma D) Absence of brain stem reflexes

A patient is scheduled for diagnostic testing to address prolonged signs and symptoms of genitourinary dysfunction. What signs and symptoms are particularly suggestive of urinary tract disease? Select all that apply.

B) Pain C) Gastrointestinal symptoms D) Changes in voiding

Dipstick testing of an older adult patients urine indicates the presence of protein. Which of the following statements is true of this assessment finding?

B) This finding is a risk factor for urinary incontinence. C) This finding is likely the result of an age-related physiologic change. D) This result confirms that the patient has diabetes.

The nurse is monitoring a patient who is receiving triple H therapy for vasospasm secondary to a subarachnoid hemorrhage. Which finding requires the nurse to immediately contact the healthcare provider?

BP 110/60

A patient hospitalized for orthopedic surgery had a urinary catheter inserted. The patient later develops a urinary tract infection (UTI) and asks the nurse what caused it. What is the appropriate response by the nurse?

Bacteria probably ascended the catheter, causing the infection.

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA) c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

C, D, A, B

The nurse is caring for a patient with chronic kidney disease. Which data collection technique is the best one for the nurse to use to determine this patients fluid volume status?

Daily weight

Which finding in the patient four hours after cystoscopy requires an intervention by the nurse?

Dark-red urine

The nurse is performing a neurologic assessment on a newly admitted head injury patient. Which sign does the nurse recognize as that most indicative of a brainstem injury?

Decerebrate posturing

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?

Decorticate posturing

A geriatric nurse is performing an assessment of body systems on an 85-year-old patient. The nurse should be aware of what age-related change affecting the renal or urinary system?

Decreased glomerular filtration rate

The nurse monitors for which therapeutic effect in the patient receiving sodium polystyrene sulfonate (Kayexalate) for the treatment of chronic kidney disease?

Decreased serum potassium

A patient recovering from an ischemic stroke is prescribed verapamil (Calan). The nurse teaches the patient that this medication works by which action?

Decreases blood pressure

The older adult who is admitted to the hospital following a closed head injury that resulted in a 5 minute period of unconsciousness will be observed for which change?

Decreasing level of consciousness (LOC)

A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase?

Dehydration

The nurse correlates which data in a patient's medical history as risk factors for acute kidney injury? SATA

Dehydration abirb.com/test Renal calculi Hypertension

Which medication prescription for the patient with chronic kidney disease needs to be questioned by the nurse?

Demerol

What concern should the nurse anticipate for a patient who had a right hemisphere stroke?

Denial of deficits and impulsiveness

The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image?

Depression

Diagnostic testing of an adult patient reveals renal glycosuria. The nurse should recognize the need for the patient to be assessed for what health problem?

Diabetes Mellitus

Which finding should the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?

Flaccidity

In assessing pain in the patient urinary tract infection which clinical manifestation does the nurse correlate to progression of the infection to pyelonephritis?

Flank pain

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patients health?

Fluid volume status

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

Start a labetalol drip to keep BP less than 140/90 mm Hg.

While collecting data, the nurse suspects that a patient is experiencing renal calculi. What did the nurse assess to come to this conclusion? (Select all that apply.)

a. Nausea b. Flank pain d. Costovertebral tenderness e. Pain radiating to the genitalia

The nurse is reinforcing teaching provided to a patient about caring for a new fistula in the left arm for dialysis. Which patient statements indicates correct understanding? (Select all that apply.)

a. Do not sleep on my arm. d. Wear loose clothing on my left arm e. Avoid carrying heavy things with my left arm. f. Do not allow blood pressures to be taken on my left arm.

A patient with a UTI is concerned about the expectation to void every three hours. What should the nurse explain to the patient about voiding this frequently? (Select all that apply.)

a. Empties the bladder b. Reduces urine stasis c. Prevents reinfection e. Lowers bacterial counts

The nurse is reinforcing teaching provided to a patient with polycystic kidney disease. Which patient statements indicate a correct understanding of the teaching? (Select all that apply.)

a. It is a hereditary disease. d. Genetic counseling is appropriate for individuals with this diagnosis. e. There is no effective treatment to stop the progression of the disease. f. It is characterized by the formation of multiple grapelike cysts in the kidney.

The home health nurse recognizes uremic signs in a patient with chronic renal failure, which include: (Select all that apply.)

a. restless legs syndrome. b. dry, scaly skin. c. urea crystals in eyebrows. d. muscle cramps.

When a patient with a urinary tract infection (UTI) is placed on cefazolin (Ancef), the nurse will monitor for: (Select all that apply.)

a. vaginitis. c. arrhythmias. d. rash. e. confusion.

The nurse is aware that an infratentorial disorder will characteristically produce

abnormal pupillary response to light.

In caring for a client who underwent renal angioplasty and stent placement, the nurse would anticipate administering a(n)

anti platelet agent

A patient with nephrotic syndrome develops flank pain. The nurse will anticipate teaching the patient about treatment with

anticoagulants.

Before hemodialysis, the nurse will withhold:

anticoagulants.

The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with:

anticoagulants.

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to

ask simple questions that the patient can answer with yes or no.

A client is in the emergency department with a suspected kidney stone and is scheduled for an intravenous pyelogram (IVP). Preprocedure, which action is most important for the nurse to do? The nurse should

ask the client about iodine allergies.

When testing comprehension in a client who is expressively aphasic, the nurse lays out a pencil, a key, and a ball and then would

ask the client to pick up the ball.

A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about

aspirin (Ecotrin).

For a client who had a transsphenoidal resection of a pituitary tumor, the nurse plans to

assess the "mustache" dressing for drainage.

The nurse would point out to a client that the advantage of magnetic resonance spectroscopy (MRS) is that the procedure

assesses markers for neurodegenerative diseases

To relieve hydronephrosis, the patient has undergone a right nephrostomy. The nursing responsibility in this condition is:

assessing urinary output from the left kidney.

A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take?

assist the patient into a chair

A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then

assist the patient into a chair.

A client who has left hemiparesis as a result of stroke is getting out of bed to the chair for the first time. The nurse should position the chair

at a right angle to the client's right side.

The nurse would assess the client with a history of TIAs for

ataxia and dysarthria.

he nurse explains that as chronic glomerulonephritis develops, the kidney:

atrophies

The nurse explains that as chronic glomerulonephritis develops, the kidney:

atrophies.

A client had an episode of acute renal failure after heart surgery but seems to have recovered now. What is an important health promotion strategy the nurse could teach the client? The nurse should teach the client to

avoid aminoglycosides and IVP dye in the future.

The nursing home administrator for a skilled nursing facility is concerned because a large number of older residents are developing UTIs. What should the staff nurse explain about the development of UTIs in this population? (Select all that apply.)

b. Diminished immune function c. Enlarged prostate in older men d. Presence of neurogenic bladder e. Decline in estrogen in older women

The nurse is contributing to the plan of care for a patient with chronic kidney disease. The nurse has recognized a growing body of evidence related to restricting protein intake. Which evidence should the nurse use to develop the plan of care? (Select all that apply.)

b. Increased protein is recommended for patients on hemodialysis. c. Protein calorie malnutrition should be avoided for patients on hemodialysis. d. Optimum nutritional status should be maintained for all patients with kidney disease f. Protein energy malnutrition is a predictor of mortality and morbidity for patients on dialysis.

The nurse is contributing to a staff education program about the risks of smoking and conditions related to smoking. Which statements by a staff member indicate correct understanding of the teaching? (Select all that apply.)

b. Kidney cancer c. Bladder cancer e. Diabetic nephropathy

A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV?

Cardiac rhythm

A patient is admitted with a stroke/brain attack. The nurse correlates which predisposing factor in the patient's history places as placing this patient at greatest risk for embolic stroke?

Carotid plaque

The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP) monitoring device. What is an advantage of this device?

Catheter tip located in the lateral ventricle

A 68-yr-old male patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching?

Catheterization technique and schedule

A patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching?

Catheterization technique and schedule

The nurse monitors for which clinical manifestations in the patient diagnosed with a left temporal node brain tumor?

Comprehensive speech difficulty

The nurse assesses the level of consciousness (LOC) of a patient with a neurologic injury as mildly disoriented to surroundings and time, but awake and needs additional verbal cues to stimulate response to commands. Which documentation is the most accurate in regard to LOC?

Confused

A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patients wife insists on feeding and dressing him, telling the nurse, I just dont like to see him struggle. Which nursing diagnosis is most appropriate for the patient?

Disabled family coping related to inadequate understanding by patients spouse

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

Provide discharge instructions about monitoring neurologic status.

Which action will the nurse anticipate taking for an otherwise healthy 50-yr-old who has just STAGE 1 RCC?

Provide preoperative teaching about nephrectomy.

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action should the nurse take?

Provide support to the spouse caregiver.

The nurse is caring for a patient status after a motor vehicle accident. The patient has developed AKI. What is the nurses role in caring for this patient? Select all that apply.

Providing emotional support for the familyMonitoring for complicationsParticipating in emergency treatment of fluid and electrolyte imbalances Providing nursing care for primary disorder (trauma)

The nurse is caring for a patient in a barbiturate coma for increased intracranial pressure (ICP). What should the nurse assess to determine this patient's cerebral function?

Pupillary size and reaction

The nurse is reviewing the history and physical of a patient who has an infection. What term should the nurse realize describes an infection of the kidneys?

Pyelonephritis

In assessing a patient with increased intracranial pressure, the nurse notes that the patient's left pupil is larger than the right pupil. The nurse correlates the larger left pupil to compression of which cranial nerve?

Left oculomotor nerve

A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider?

Left-sided flank pain

Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care provider?

Left-sided flank pain

In assessing the patient with a significant rightsided closed head injury, the nurse would anticipate the patient to demonstrate which sign?

Leftsided motor deficit with sluggish right pupil response

The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate?

Level Of Consciousness

When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first?

Place the patient on a cardiac monitor.

A patient with chronic kidney disease has a serum potassium level of 6 mEq/L. Which action should the nurse take? (Select all that apply.)

Place the patient on a cardiac monitor. Inform RN to notify physician.

In a patient with acute kidney injury (AKI) who requires hemodialysis, a temporary vascular access is obtained by placing a catheter in the left femoral vein. Which intervention will be included in the plan of care?

Place the patient on bed rest.

A patient gives the admitting nurse health information before a scheduled intravenous pyelogram (IVP). Which item requires the nurse to intervene before the procedure?

The patient lists allergies to shellfish and penicillin.

The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the patients neurologic assessment?

Loss of voluntary control of movement

A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?

MRI

A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of care, what goal should be prioritized?

Maintain and improve cerebral tissue perfusion

The nurse has identified the nursing diagnosis of risk for infection in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk?

Maintain aseptic technique when administering dialysate.

A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patients plan of care?

Maintain the patient on complete bedrest

The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. What will be the primary treatment goal in the plan?

Maintaining cardiac output

A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient?

Managing postoperative pain

The nurse is writing the care plan for a cerebrovascular accident (CVA) patient who has partial leftsided paralysis and is experiencing ataxia. Which intervention will be beneficial for this patient?

Place the patient's call light on the right side of the patient and remind her to call for assistance before getting up.

A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?

Noncontrast computed tomography (CT) scan

The nurse notes that the urine from a patient with an ileal conduit has mucus strands. What action should the nurse take?

Nothing, as the nurse understands that this is a normal finding.

Which assessments should the nurse make to monitor a patient's cerebellar function? (Select all that apply.)

Observe arm swing with gait. Perform the finger-to-nose test.

Which nursing actions should be included in the plan of care for a patient after cerebral angiography? (Select all that apply.)

Observe for bleeding at the puncture site. Check pulse and blood pressure frequently. Assess orientation to person, place, and time.

A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties?

Place the patients extremities where she can see them.

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin?

The patient reports that symptoms began with a severe headache.

A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient?

The patient should be approached on the side where visual perception is intact.

The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patients plan of care?

The patient should be placed in a prone position for 15 to 30 minutes several times a day.

A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what principle of care?

The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family?

The patient should mobilize as soon as she is physically able

. A patient has just returned to the nursing unit after having a renal biopsy. When planning the patient's care, which instruction will most likely be included?

The patient should remain flat in bed for at least 6 hours after the procedure.

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?

The patient states, My symptoms started with a terrible headache.

When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider?

The patient takes warfarin (Coumadin) daily.

While admitting a 42-yr-old patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

The patient takes warfarin (Coumadin) daily.

When caring for a patient after cystoscopy, what should the nurse include in the plan of care?

The patient understands to expect blood-tinged urine.

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

The patient's blood pressure (BP) is 90/50 mm Hg.

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider?

The patient's central venous pressure (CVP) is decreased.

A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider?

The patient's peritoneal effluent appears cloudy.

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address?

The patient's usual blood pressure (BP) is 170/94 mm Hg.

The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)?

The patients average urine output has been 10 mL/hr for several hours.

The nurse is assessing a patients bladder by percussion. The nurse elicits dullness after the patient has voided. How should the nurse interpret this assessment finding?

The patients bladder is not completely empty.

The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address?

The patients blood pressure (BP) is usually about 180/90 mm Hg.

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?

The patients blood pressure is 86/42 mm Hg.

A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?

The patients blood pressure is 90/50 mm Hg.

Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider?

The patients central venous pressure (CVP) is decreased.

A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurses care of this patient?

The patients disease is incurable and the nurses interventions will be supportive.

Results of a patients 24-hour urine sample indicate osmolality of 510 mOsm/kg, which is within reference range. What conclusion can the nurse draw from this assessment finding?

The patients kidneys can produce sufficiently concentrated urine.

The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider?

The patients peritoneal effluent appears cloudy.

Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective?

The periorbital and peripheral edema are resolved.

What questions does the nurse ask when conducting an expanded assessment to determine patient orientation? SATA

"2. "What state are you in right now?" 4. "What are names of your children?" 5. "What kind of place are we in right now?"

A client with renal failure has an order to infuse dopamine (Intropin) to activate the dopamine receptors in the kidney. The nurse would set the infusion rate for

1 to 5 g/kg/minute.

What should be included in the patients care plan when establishing an exercise program for a patient affected by a stroke?

Exercise the affected extremities passively four or five times a day.

The nurse monitors for which clinical manifestations in the patient experiencing an ischemic stroke of the basilar artery? Select all that apply.

1. Ataxia2. Nausea3. Dysphasia4. Inability to swallow 5. Difficulty with speech

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take?

Explain that the aspirin is ordered to decrease stroke risk.

Which nursing action is essential for a patient immediately after a renal biopsy?

Apply a pressure dressing and position the patient on the affected side.

A patient in the oliguric phase of acute renal failure has a 24-hour fluid output of 150 mL emesis and 250 mL urine. The nurse plans a fluid replacement for the following day of ___ mL.

1000

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How should the nurse record the patient's Glasgow Coma Scale score?

11

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patients Glasgow Coma Scale score as

11

. A patient hourly urine output is recorded. Which output rates should be brought to the attention of the registered nurse (RN) immediately?

15 mL/hr

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, I dont need the aspirin today. I dont have any aches or pains. Which action should the nurse take?

Explain that the aspirin is ordered to decrease stroke risk.

Which data in an older adult's history does the nurse correlate as risk factors for developing acute kidney injury? SATA

1. Diagnosed with hypotension 2. Recent aortic valve replacement surgery 3. Prescribed high doses of intravenous antibiotics

Which observations by the nurse are representative of the symptomology of an epidural hematoma (EDH)?

1. History of unconsciousness immediately after trauma 3. Rapid deterioration in level of consciousness 4. Period of lucidity prior to onset of symptoms 5. Dilated pupil on the same side as the injury

Which physiologic factors result in the secretion of aldosterone from the kidneys? Select all that apply.

1. Hyponatremia 3. Hypotension 4. Hyperkalemia

What laboratory values does the nurse need to assess before a patient receives a hemodialysis treatment? SATA

1. Increased blood urea nitrogen (BUN) 5. Increased creatinine

A patient with increased intracranial pressure (ICP) is being repositioned. The nurse would incorporate which actions into this intervention?

1. Inform the patient regarding what is going to occur during the intervention. 4. Elevate the head of the bed to 30 degrees. 5. Manage the repositioning with slow, smooth, and gentle movements

A patient is demonstrating signs of increasing ICP. Which nursing actions are indicated to decrease ICP? SATA

1. Placing the head in a neutral position 3. Raising the head of the bed 60 degrees

In monitoring a patients renal function, ADH is released in response to which physiological factors?

1. Urine specific gravity 1.042 4. Serum osmolality 310 mOsm/L 3. Serum sodium 148

In providing care to a patient with hyperglycemia and normal renal function, the nurse correlates the renal threshold for glucose to which value?

Greater than 220 mg/dL

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care?

Apply intermittent pneumatic compression stockings

A patient is complaining of genitourinary pain shortly after returning to the unit from a scheduled cystoscopy. What intervention should the nurse perform?

Apply moist heat to the patients lower abdomen.

A patient has developed severe postsurgical muscle weakness in the lower extremities after the removal of a brain tumor. The nurse takes which initial intervention to minimize the patients risk of developing a deep vein thrombosis (DVT)?

Apply well-fitted antiembolism hose

A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?

Applying intermittent pneumatic compression stockings

The nurse caring for a patient with suspected renal dysfunction calculates that the patients weight has increased by 5 pounds in the past 24 hours. The nurse estimates that the patient has retained approximately how much fluid?

2,300 mL of fluid in 24 hours

The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurses most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurses best response?

Assess the patient for signs of bleeding and inform the physician.

The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize?

Assessment of the quantity of the patients urine output

The nurse is planning a community education session regarding prevention of traumatic brain injury (TBI). The nurse would discuss which risk factors

2. Male gender 4. High alcohol intake 5. Serving in the military

The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping?

Assist the family in setting appropriate short-term goals.

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program?

Assist the patient onto the bedside commode every 2 hours.

Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care?

Assist the patient onto the bedside commode every 2 hours.

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care?

Assist the patient to eat with the left hand.

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care?

Assist the patient to eat with the right hand.

The nurse is completing a care plan for a stroke patient who is at risk for impaired physical mobility. Which interventions should the nurse include in the care plan? (Select all that apply.)

Assist the patient to stand. Ensure that the call bell is easily available. Coach the patient in active ROM. Reinforce the use of a walker or cane.

The nurse recognizes that the patient with blood loss is at risk of renal damage because the kidney receives what percentage of the total cardiac output?

20% to 25%

The nurse recommends that, in order to keep optimum flow through the urinary system, a person should have a minimum intake of _____ mL/day.

2000 to 2500

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order in which they occur.

236145

The unconscious patient with a closed head injury is on mechanical ventilation. To improve brain perfusion through increased blood pressure, the CO2 level is maintained at _____ mm Hg.

25 to 30

Preparing an educational program about urolithiasis, the nurse explains which person is at greatest risk for this disorder?

28-year-old Caucasian male who works as a lifeguard at a beach in Florida

An emergency department nurse is admitting a client with ischemic stroke who is eligible for thrombolytic therapy. The nurse works quickly to provide care, knowing that for this therapy to be effective, it must be administered in a poststroke time window of

3 hours

A patient with increased intracranial pressure (ICP) is sensitive to fluid-volume shifts. The nurse recognizes which approach as safest to reduce this patient's cerebral edema?

3% sodium chloride

Following an open loop resection and fulguration of the bladder, a patient is unable to void. Which nursing action should be implemented first?

Assist the patient to take a 15-minute sitz bath.

A 68-yr-old patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care?

Assist the patient to the bathroom every 2 hours during the day.

A 78-year-old who has been admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care?

Assist the patient to the bathroom every 2 hours during the day.

After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first?

Assure that the patients neck is not in a flexed position.

The nurse is performing a focused genitourinary and renal assessment of a patient. Where should the nurse assess for pain at the costovertebral angle?

At the lower border of the 12th rib and the spine

The nurse monitors for which clinical manifestations of increased intracranial pressure in the patient diagnosed with a brain tumor? Select all that apply.

Ataxia Papilledema Vomiting Headache

A nurse is caring for a patient with impaired renal function. A creatinine clearance measurement has been ordered. The nurse should facilitate collection of what samples?

A 24-hour urine specimen and a serum creatinine level midway through the urine collection process

The staff educator is giving a class for a group of nurses new to the renal unit. The educator is discussing renal biopsies. In what patient would the educator tell the new nurses that renal biopsies are contraindicated?

A 42-year-old patient with morbid obesity

Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit?

A 44-year-old receiving IV antibiotics for meningococcal meningitis

A patient at risk for increased intracranial pressure (ICP) is likely to experience involuntary compensatory mechanisms. The nurse would monitor this patient for signs of which involuntary compensation?

3. Decreased production of cerebral spinal fluid (CSF) 4. Decreased metabolic energy needs 5. Increased absorption of cerebral spinal fluid (CSF)

After the emergency department nurse has received a status report on the following patients with head injuries, which patient should the nurse assess first?

A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

After receiving change-of-shift report on the following four patients, which patient should the nurse see first?

A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed

When a patient is put on a sulfa drug, the nurse adds interventions to the nursing care plan to increase the daily fluid intake to a minimum of _____ mL/day.

3000

The nurse is reinforcing 24-hour fluid intake teaching for a patient to prevent further UTIs. Which amount should the patient state that indicates that teaching has been effective?

3000 mL.

A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patients diet to maximize the therapeutic effect and minimize the risks of complications. The patients diet should include which of the following modifications? Select all that apply.

A) Decreased protein intake B) Decreased sodium intake c.) Fluid restrictions

Which action will the nurse include in the plan of care to maintain the patency of a patient's left arm arteriovenous fistula?

Auscultate for a bruit at the fistula site.

The nurse is caring for a patient admitted for treatment of a subarachnoid hemorrhage caused by a cerebral aneurysm who has a wide neck and tortuous vascular anatomy. The patient is hemodynamically stable with Glasgow Coma Scale of 14. Based on this data, the patient is most likely to have which procedure?

Aneurysm clipping

The nurse is caring for a patient who has an acute kidney injury. Which diagnostic test result should the nurse identify as most supporting this diagnosis?

Blood urea nitrogen 20 mg/100 mL (normal 8 to 25 mg/100 mL)

The result of a patients creatinine clearance test is 60 mL/min. The nurse equates this finding to a glomerular filtration rate (GFR) of _____ mL/min.

60

What glomerular filtration rate (GFR) would the nurse estimate for a 30-yr-old patient with a creatinine clearance result of 60 mL/min?

60 mL/min

A patient is diagnosed with end-stage kidney disease. The nurse realizes that what percentage of functioning nephrons have been lost in this patient?

90%

A patient who had a kidney transplant eight years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone. Which assessment data will be of most concern to the nurse?

A NONTENDER AXILLAR LUMPY

A kidney biopsy has been scheduled for a patient with a history of acute renal failure. The patient asks the nurse why this test has been scheduled. What is the nurses best response?

A biopsy is sometimes necessary for diagnosing and evaluating the extent of kidney disease.

The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patients atmosphere more conducive to communication?

Provide a board of commonly used needs and phrases.

A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft?

A fistula is much less likely to clot.

A patient asks the nurse why kidney problems can cause gastrointestinal disturbances. What relationship should the nurse describe?

A patient asks the nurse why kidney problems can cause gastrointestinal disturbances. What relationship should the nurse describe?

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?

A patient whose right pupil is 10 mm and unresponsive to light

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess first?

A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram

The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD?

A patient with diabetes mellitus and poorly controlled hypertension

After receiving change-of-shift report on the following four patients, which patient should the nurse see first?

A patient with right-sided weakness who has an infusion of tPA prescribed

The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula?

A vein and an artery in your arm will be attached surgically.

What action should the nurse take first when a patient's urine dipstick test indicates a small amount of protein?

Inquire about which medications the patient is currently taking.

Which interventions should the nurse plan to encourage the client to become proficient in self administering his/her own medications? (Select all that apply.)

Allow the client to assume greater responsibility for taking medications. Create a clear, concise drug chart including all the client's medications. Provide a supervised trial of selfadministration of medications. Teach the client pertinent information about each medication.

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment. What action is best for the nurse to take?

Allow the family to stay with the patient and briefly explain all procedures to them.

Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patients spouse and children stay at the patients side and constantly ask about the treatment being given. What action is best for the nurse to take?

Allow the family to stay with the patient and briefly explain all procedures to them.

When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware?

Alteration in LOC

An 88-year-old with benign prostatic hyperplasia (BPH) has a markedly distended bladder and is agitated and confused. Which of the following interventions prescribed by the health care provider should the nurse implement first?

Insert a urinary retention catheter.

The patient was riding in a car that hit a tree. The head hit the windshield, and then the brain rebounded within the skull toward the opposite side. This injury represents which mechanism of injury?

An acceleration-deceleration injury

A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first?

Insert an indwelling urinary catheter.

The nurse is aware that an epidural hematoma warrants immediate intervention based on which criteria? (Select all that apply.)

An epidural hematoma can increase intracranial pressure quickly. An epidural hematoma changes overall condition quickly. An epidural hematoma can cause death. An epidural hematoma can cause irreversible brain damage.

The nurse is caring for a patient who has a fluid volume deficit. When evaluating this patients urinalysis results, what should the nurse anticipate?

An increased urine specific gravity

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question?

Insert nasogastric tube to low suction.

What term does the nurse use when documenting that the patient has less than 100 ml of urine output in 24 hour period?

Anuria

A patient who had a bladder repair following an injury from an automobile accident complains of pain. Which action would be considered an independent nursing intervention that does not require a physician's order?

Apply a cold compress to the surgical site.

A patient who had a bladder repair following an injury from an automobile accident complains of pain. Which action would be considered an independent nursing intervention that does not require a physicians order?

Apply a cold compress to the surgical site.

A patient with diabetic nephropathy is admitted for a right renal biopsy. Immediately after the biopsy, which of these is an essential nursing action?

Apply a pressure dressing and keep the patient on the affected side for 30 to 60 minutes.

The nurse is reinforcing teaching provided to a patient with chronic kidney disease. Which patient statement indicates the need for further teaching?

As long as I dont eat protein, Ill be okay.

A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patients care should the nurse begin to use a neurologic flow chart?

As soon as the initial assessment is made

A female patient being admitted with pneumonia has a history of neurogenic bladder due to a spinal cord injury. Which action will the nurse plan to take first?

Ask about the usual urinary pattern and any measures used for bladder control.

Which of the following actions will the nurse plan to take first when admitting a patient who has a history of neurogenic bladder as a result of a spinal cord injury?

Ask about the usual urinary pattern and any measures used for bladder control.

When admitting an acutely confused patient with a head injury, which action should the nurse take?

Ask family members about the patient's health history.

A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate?

Ask questions that the patient can answer with "yes" or "no."

A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take?

Ask the patient about current medications.

A patient with a possible urinary tract infection (UTI) gives the nurse in the clinic a urine specimen that is a red-orange color. Which action should the nurse take first?

Ask the patient about use of any medications.

A patient diagnosed with a brain tumor is reluctant to agree to a surgical excision of the lesion. How can the nurse best address the patients concerns?

Asking the patient to be more specific about the concerns

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient?

Aspirin

The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the womans medications carries the greatest potential for reducing her risk of stroke?

Aspirin 81 mg PO

A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care?

Assess for a thrill or bruit over the vascular access site each shift.

The nurse is caring for a patient with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply.

Assess for the presence of peripheral edema. Assess the patients BP.

Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis? (Select all that apply.)

Avoid commercial salt substitutes. Take phosphate binders with each meal. Choose high-protein foods for most meals.

The patient with a suspected subdural hematoma is on an IV drip of mannitol infusing at 50 mL/hr. The nurse explains that the slow infusion rate is essential for what purpose?

Avoid fluid overload.

Which nursing action will be most helpful in decreasing the risk for hospital-acquired infection (HAI) of the urinary tract in patients admitted to the hospital?

Avoid unnecessary catheterizations.

Nursing staff on a hospital unit are reviewing rates of health care-associated infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for urinary HAI in patients admitted to the hospital?

Avoiding unnecessary urinary catheterization

While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patients nose. Which of these admission orders should the nurse question?

Insert nasogastric tube.

The nurse is reviewing the electronic health record of a patient with a history of incontinence. The nurse reads that the physician assessed the patients deep tendon reflexes. What condition of the urinary/renal system does this assessment address?

Bladder dysfunction

The patient sustains a subdural hematoma after falling. How would the nurse explain this injury to the patients family?

Bleeding is occurring between the brain and its covering

Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

Blood pressure 156/60, pulse 55, respirations 12

The nurse correlates which finding in a patient's history as the highest risk for a stroke?

Blood pressure 182/90 mm Hg

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?

Blood pressure 88/45 mm Hg

Which finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?

Blood pressure 90/48 mm Hg

A patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first?

Insert retention catheter.

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

Bradycardia and hypertension

In monitoring a trauma patient for shock, the nurse differentiates neurogenic shock from hypovolemic shock by correlating which parameters to neurogenic shock?

Bradycardia with decreased afterload

A client who has had a stroke appears to understand words that are spoken but cannot verbally respond. The nurse clarifies that this type of aphasia is

Brocas

The nurse correlates which clinical manifestation in the patient diagnosed with a basilar skull fracture?

Bruising around the ears

Which assessment data reported by a patient is consistent with a lower urinary tract infection (UTI)?

Burning on urination

An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for surgical treatment. The patient has been on chemotherapeutic agents to decrease the tumor size prior to the planned surgery. The nurse caring for the patient is aware that what precipitating factors in this patient may contribute to AKI? Select all that apply.

C) Age-related physiologic changes D) Chronic systemic disease

A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurses primary assessment focus?

Cardiac and Respiratory status

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?

CT scan

In assessing the cause of the decreased level of consciousness in a client in a coma, the diagnostic procedure that would provide the most accurate information is

CT scan

Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)?

CVA tenderness

Which information will be most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)?

Calculated glomerular filtration rate (GFR)

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel (Plavix)?

Call the health care provider if stools are tarry.

After ureterolithotomy, a patient has a left ureteral catheter and a urethral catheter in place. Which action will the nurse include in the plan of care?

Call the health care provider if the ureteral catheter output drops suddenly.

Which action will the nurse include in the plan of care for a patient who has had a ureterolithotomy and has a left ureteral catheter and a urethral catheter in place?

Call the health care provider if the ureteral catheter output drops suddenly.

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Call the physician immediately

The nurse recognizes that which disease process places the patient at the greatest risk for neurogenic shock?

Cervical spine injury

Which nursing action should the nurse who is caring for a patient who has had an ileal conduit for several years delegate to nursing assistive personnel (NAP)?

Change the ostomy appliance.

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first?

Check blood pressure and heart rate.

A patient has arrived for a scheduled hemodialysis session. Which nursing action is appropriate for the registered nurse (RN) to delegate to a dialysis technician?

Check blood pressure before starting dialysis.

Which nursing action for a patient who has arrived for a scheduled hemodialysis session is most appropriate for the RN to delegate to a dialysis technician?

Check blood pressure before starting dialysis.

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to the unlicensed assistive personnel (UAP) who regularly works in the intensive care unit?

Check capillary blood glucose level every 6 hours.

The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit?

Check capillary blood glucose level every 6 hours.

During routine hemodialysis, a patient reports nausea and dizziness. Which action should the nurse take first?

Check the blood pressure (BP).

After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which action should the nurse take first?

Check the chart for the most recent blood potassium level.

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?

Check the drainage for glucose content.

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula?

Check the fistula site for a bruit and thrill.

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take?

Check the nasal drainage for glucose.

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first?

Check the patient's most recent potassium level.

During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first?

Check the patients blood pressure.

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Check the respiratory rate and effort.

A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Check the respiratory rate.

The nurse is examining an adult patient. For what purpose would the nurse use palpation?

Checking for bladder distention

A nurse is planning care for a client who has chronic kidney disease. Which of the following interventions would help the client meet a priority outcome?

Instruct the client not to get out of bed without assistance.

A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding?

Clonus

The nurse planning the care of a patient with head injuries is addressing the patients nursing diagnosis of sleep deprivation. What action should the nurse implement?

Cluster overnight nursing activities to minimize disturbances.

The nurse is reinforcing teaching provided to a patient with a history of calcium oxalate kidney stones. The nurse recognizes that teaching has been effective if the patient avoids which foods? (Select all that apply.)

Cocoa Spinach Instant coffee

A patient with a traumatic brain injury is leaking clear fluid from the nose. What action should the nurse take?

Collecting the fluid with glaze

The nurse is caring for an unstable patient with acute kidney injury. What therapy should the nurse expect to be ordered?

Continuous renal replacement therapy (CRRT)

A patient is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the patient develops acute kidney injury. The patient is hemodynamically unstable, but renal replacement therapy is needed to manage the patients hypervolemia and hyperkalemia. Which of the following therapies will the patients hemodynamic status best tolerate?

Continuous venovenous hemodialysis (CVVHD)

The nurse correlates which clinical manifestations in the patient diagnosed with a grade 1 renal trauma? SATA

Contusion Hematuria

A 72-year-old who has benign prostatic hyperplasia is admitted to the hospital with chills, fever, and vomiting. Which finding by the nurse will be most helpful in determining whether the patient has an upper urinary tract infection (UTI)?

Costovertebral tenderness

A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. What should the nurse teach the patient about hemodialysis?

Hemodialysis is a treatment option that is usually required three times a week.

The nurse is administering peritoneal dialysis to a patient with acute kidney injury and notes the presence of a cloudy dialysate return. After notifying the healthcare provider, which action by the nurse is best?

Culture the dialysate return

A patient has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the patient about what topic?

Current medication use

The nurse is providing care to a patient who requires the removal of a kidney stone. Which procedure does the nurse anticipate will be ordered for this patient?

Cystoscopy

The nurse prepares the patient with suspected bladder cancer for which diagnostic test that is needed for definitive diagnosis?

Cystoscopy with biopsy

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect?

Difficulty comprehending instructions

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find?

Difficulty in understanding commands

In administering an alpha-adrenergic blockers to a patient diagnosed with urolithiasis, the nurse correlates the primary rationale to this medication to which mechanism of action?

Dilate lower ureter

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems?

Diminished deep tendon reflexes

The nurse observes nursing assistive personnel (NAP) taking the following actions when caring for a patient with a retention catheter. Which action requires that the nurse intervene?

Disconnecting the catheter from the drainage tube to obtain a specimen

A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patients plan of care?

Disturbed sensory perception

When reading a patients chart, the nurse notes that the patient has dysuria. To assess whether there is any improvement, which question will the nurse ask?

Do you have any pain when you urinate?

The nurse completing a physical assessment for a newly admitted patient is unable to feel either kidney on palpation. Which action should the nurse take?

Document the information on the assessment form.

While assessing a patients urinary system, the nurse cannot palpate either kidney. Which action should the nurse take next?

Document the information on the assessment form.

A patient with a history of progressively worsening fatigue is undergoing a comprehensive assessment which includes test of renal function relating to erythropoiesis. When assessing the oxygen transport ability of the blood, the nurse should prioritize the review of what blood value?

Hemoglobin

What should the nurse include when teaching an adult patient to prevent the recurrence of kidney stones?

Drink 3000 ml of fluid each day

A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient?

Drink liberal amounts of fluids.

The nurse on a rehabilitation unit is caring for a stroke patient who is experiencing homonymous hemianopsia. The patient asks if he is going to have any limitations when discharged from the hospital. The nurse anticipates the patient will be restricted from what activity?

Driving a vehicle

When the nurse is caring for a patient who has had left-sided extracorporeal shock wave lithotripsy, which assessment finding is most important to report to the health care provider?

Drop in urine output

What term does the nurse use to document a patient's complaints of painful urination?

Dysuria

Following a craniotomy to relieve increased intracranial pressure (ICP), the nurse will implement which intervention?

Elevate the head of the bed 30 to 45 degrees.

When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal?

Elevation of the HOB

The nurse is caring for a client who had a stroke several years ago. The client has indicators of being malnourished. The nurse would assess the client for which of the following?

Embarrassment and frustration over trouble eating

A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

Emergency craniotomy

What should the nurse will teach about when preparing a patient with bladder cancer for intravesical chemotherapy?

Emptying the bladder before the instillation

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?

Encourage family members to remain at the bedside.

The nurse is reinforcing teaching provided to a patient about risk factors for prerenal injury. Which risk factor should the patient state that indicates understanding of this teaching?

Enlarged prostate.

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?

Ensure that the patient's neck is in neutral position.

The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?

Ensure that the player is not moved.

The nurse is caring for a patient who has a nephrostomy tube. What action should the nurse take to maintain the integrity of this device?

Ensure tube is not kinked or clamped.

What term does the nurse use ato bdoicrubm.ecntoa mpati/etnet'sctomplaints of involuntary urination at night?

Enuresis

A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patients care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include?

Excess fluid volume related to generalized edema

A patient who is diagnosed with nephrotic syndrome has 3+ ankle and leg edema and ascites. Which nursing diagnosis is a priority for the patient?

Excess fluid volume related to low serum protein levels

A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?

Evidence of a hemorrhagic stroke

A 58-yr-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which patient problem is present, based on these findings?

Excess fluid volume

A patient is being treated for AKI and the patient daily weights have been ordered. The nurse notes a weight gain of 3 pounds over the past 48 hours. What nursing diagnosis is suggested by this assessment finding?

Excess fluid volume

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?

Facial Droop

Given the diagnosis of acute glomerulonephritis, the appropriate nursing diagnosis would be

Fatigue related to increased metabolic demands and anemia

The nurse is caring for a patient suspected of having renal dysfunction. When reviewing laboratory results for this patient, the nurse interprets the presence of which substances in the urine as most suggestive of pathology?

Glucose and protein

Which of the following information obtained by the nurse who is caring for a patient with end-stage renal disease (ESRD) indicates the nurse should consult with the health care provider before giving the prescribed epoetin alfa (Procrit)?

Hemoglobin level 13 g/dL

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. What should the nurse suspect as a likely cause of these findings?

Frontal lobe damage

When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause?

Frustration around changes in function and communication

A patient with a cerebral vasospasm is receiving triple H therapy. What parameter should the nurse use to determine adequacy of hemodilution?

Hemoglobin level 30 g/dL

A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?

GFR

A 26-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having knee surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider?

Give ketorolac (Toradol) 10 mg PO PRN for pain.

A patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider?

Give ketorolac 10 mg PO PRN for pain.

In planning an educational presentation about age-related changes of the renal system, the nurse includes which information?

Glomerular filtration rate decreases with age.

The nurse correlates which disorder to the development of intrarenal renal failure?

Glomerulonephritis

A young adult male patient seen at the primary care clinic reports feeling continued fullness after voiding and a split, spraying urine stream. What should the nurse ask about the patient's history?

Gonococcal urethritis

What grade renal trauma does the nurse document in the patient experiencing hematuria and contusions but with normal imaging studies?

Grade 1

What grade of renal trauma does should the nurse document in the patient who has a renal laceration that is greater than 1 cm in depth but does not involve the collecting system?

Grade 3

A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has?

Grade 3 concussion with temporal lobe involvement

A patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the health care provider?

HR 102

The nurse assesses the client for the electrolyte imbalance that tends to occur in the earlier stages of chronic renal failure, which is

HYPOKALEMIA

A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patients safety during mobilization, the nurse should perform what action?

Have a colleague follow closely with a wheelchair

A patient with glomerulonephritis asks, How could I have gotten this? How should the nurse respond?

Have you had a sore throat or skin infection recently?

A 19-year-old patient reports flank pain and scanty urination. The nurse notices periorbital edema, and the urinalysis reveals white blood cells, red blood cells, albumin, and casts. What question would be most important for the nurse to include in data collection?

Have you had a strep infection of the throat or skin recently?

A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include?

How to correctly modify the home environment

Renal failure can have prerenal, renal, or postrenal causes. A patient with acute kidney injury is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused it?

Heart Failure

Which assessment finding for a patient who has had a cystectomy with an ileal conduit the previous day is most important for the nurse to communicate to the physician?

Heart rate 102 beats/minute

In monitoring a patient recovering from a craniotomy for treatment of a brain tumor, which assessmentfindingsrequirethaenburisrebto.cnootifmyth/etesusrgteon?Selectallthatapply.

Heart rate 52 bpm RR 10 and unregular Systolic BP 198

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?

Help distinguish reduced renal blood flow from decreased renal function

A client has nephritis. Which intervention can the nurse institute to best encourage the client to attain adequate emotional rest?

Help the client deal with emotional reactions.

An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury?

Hematoma

The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem?

Hematuria

The nurse is collecting data from a patient with suspected cancer of the bladder. What finding should the nurse recognize as the most common symptom of cancer of the bladder?

Hematuria

What term does the nurse use to document a patient's complaints of blood in the urine?

Hematuria

The nurse monitors for which clinical manifestations in the patient diagnosed with acute glomerulonephritis? SATA

Hematuria Proteinuria Serum creatinine 2.4 mg/dL

A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason?

Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.

Which medications does the nurse identify as potentially nephrotoxic when conducting a health history exam for a patient who is admitted for acute kidney disease? Select all that apply.

Ibuprofen (Advil) Lithium (Lithobid) Rifampin (Rifadin)

A patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which of these orders for the patient will the nurse question?

Ibuprofen (Advil) 400 mg PO PRN for pain

Plasmapheresis has been ordered for the patient diagnosed with glomerulonephritis. Before the procedure, the patient correctly reports that the procedure will help her when she states that it will:

Identify specific organisms causing my disease.

When feeding a patient with dysphagia with a leftsided hemiplegia, how should the nurse position the patient?

High Fowler's

A patient who suffered a thrombotic stroke has residual left lower extremity motor deficit and dysphagia. The nurse identifies which of the following as the priority nursing diagnosis?

High Risk for Aspiration

The nurse notes it is time to administer prescribed gentamicin (Garamycin) for a patient with acute kidney injury and suspected streptococcal pneumonia. Which action should the nurse take at this time? (Select all that apply.)

Hold medication Consult physician about medication order.

The nurse is providing pre-procedure teaching about an ultrasound. The nurse informs the patient that in preparation for an ultrasound of the lower urinary tract the patient will require what?

Increased fluid intake to produce a full bladder

The nurse working with an unconscious client to develop a holistic nursing care plan would include the family and which highpriority nursing diagnosis?

Interupted family process

After an older adult falls, the nurse suspects the development of a subdural hematoma based on which assessment findings? (Select all that apply.)

Increasing irritability Complaint of a dull headache Frequent "nodding off" in chair during the day

In providing care to the patient who may have polycystic kidney disease, the nurse recognizes which finding as the first clinical manifestation of this disease process?

Hypertension

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?

Hyperthermia

Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?

I am going to drive home and go to bed.

A patient who had a cystoscopy the previous day calls the urology clinic and gives the nurse all the following information. Which statement by the patient should be reported immediately to the health care provider?

I have a temperature of 101.

After teaching a patient with interstitial cystitis about management of the condition, the nurse determines that further instruction is needed when the patient says,

I should start taking a high potency multiple vitamin every morning.

After the home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying, which patient statement indicates that the teaching has been effective?

I will clean the catheter carefully before and after each catheterization.

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) for a patient with cystitis has been effective when the patient states,

I will empty my bladder every 3 to 4 hours during the day.

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurses teaching about management of CKD has been effective?

I will measure my urinary output each day to help calculate the amount I can drink.

Which statement by the patient after radical nephrectomy for renal cancer indicates the need for further teaching?

I will notify you if my urine is pink tinged

The nurse is reinforcing teaching provided to a patient about antibiotics prescribed for a UTI. Which patient statement indicates teaching has been effective?

I will take the antibiotics until they are gone regardless of symptoms.

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?

ICP

The nurse evaluates a need for further instruction about a sodium-restricted diet when the patient with glomerulonephritis says:

Im glad I can still drink carbonated drinks.

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important?

Immunize adolescents and college freshman against Neisseria meningitides.

A 32-year-old patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time?

Importance of genetic counseling

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient?

Intracranial pressure

A patient with glomerulonephritis develops acute kidney injury. Which form of kidney injury should the nurse realize has occurred with this patient?

Intrarenal

A nurse knows that specific areas in the ureters have a propensity for obstruction. Prompt management of renal calculi is most important when the stone is located where?

In the ureteropelvic junction

When the patient reports he has blood in his urine the moment he starts to void that disappears until the next time he voids, the nurse is aware that the source of the bleeding is most probably:

In the urethra

The nurse includes which information in an educational presentation to staff about the development of urolithiasis?

Incidence is greater in men.

The nurse has admitted a new patient to the unit. One of the patients admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system?

Increased Heart Rate

A nurse is working with a patient who will undergo invasive urologic testing. The nurse has informed the patient that slight hematuria may occur after the testing is complete. The nurse should recommend what action to help resolve hematuria?

Increased fluid intake following the test

The nurse is providing care to a patient who is experiencing symptoms of a kidney stone. Which diagnostic tool does the nurse anticipate to be ordered for this patient?

Intravenous urography

A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action?

Inform the physician and assess the patient for signs of infection.

A creatinine clearance test is ordered for a hospitalized patient with possible renal insufficiency. Which equipment will the nurse need to obtain?

Large container for urine

A hospitalized patient who has possible renal insufficiency after coronary artery bypass surgery will have a creatinine clearance test. Which item will the nurse need to obtain?

Large urine container

A 78-yr-old patient has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care?

Leave a light on in the bathroom during the night.

An 82-year-old man has been admitted with benign prostatic hyperplasia. Which of the following is most appropriate to include in the nursing plan of care?

Leave a light on in the bathroom during the night.

The nurse is caring for a patient who had kidney transplantation several years ago. Which assessment finding may indicate that the patient is experiencing adverse effects to the prescribed corticosteroid?

Joint pain

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

Keep the head of the bed elevated to 30 degrees

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

Keep the head of the bed elevated to 30 degrees.

The nurse is caring for a patient who is going to have an open renal biopsy. What would be an important nursing action in preparing this patient for the procedure?

Keep the patient NPO prior to the procedure.

A 71-year-old patient with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The patient tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make?

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

Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid taken for four years after kidney transplantation?

Knee and hip joint pain

Following a craniotomy for the removal of a brain tumor, the patient exhibits nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. What do these assessment findings indicate to the nurse?

Meningitis

A patient with chronic kidney disease (CKD) brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required?

Milk of magnesia 30 mL

The nurse is contributing to the plan of care for a patient who is having an intravenous pyelogram (IVP) done to diagnose possible bladder cancer. Which intervention should the nurse recommend be included for the patient after the procedure?

Monitor creatinine level.

A hospitalized patient with a decreased glomerular filtration rate is scheduled to have an intravenous pyelogram (IVP). Which action will be included in the plan of care?

Monitor the urine output after the procedure.

The nurse is caring for a hospitalized patient with a decreased glomerular filtration rate who is scheduled for an intravenous pyelogram (IVP). Which action will be included in the plan of care?

Monitor the urine output after the procedure.

Which topic should the nurse include when planning a teaching session for a patient with benign nephrosclerosis?

Monitoring and recording blood pressure

A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching?

More protein is allowed because urea and creatinine are removed by dialysis.

When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching?

More protein will be allowed because of the removal of urea and creatinine by dialysis.

The anxious mother of an adolescent who sustained a spinal injury yesterday and has paralysis of the lower limbs asks if the paralysis is permanent. Which response by the nurse is most helpful?

Motor function sometimes returns after the edema of the spinal cord has subsided."

During a patients recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.

National Institutes of Health Stroke Scale (NIHSS) score LOC at the time of admission Age

The nurse is caring for a patient who is being treated for acute pyelonephritis. When performing the assessment, the nurse correctly recognizes that which symptom is consistent with the early stages of the disease?

Nausea

A 46-yr-old female patient returns to the clinic with continued dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take?

Obtain a midstream urine specimen for culture and sensitivity testing.

A patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take?

Obtain a midstream urine specimen for culture and sensitivity testing.

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

Obtain oxygen saturation.

A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patients left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes?

Occipital

The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy?

Preserving brain homeostasis

A 28-yr-old male patient has just been diagnosed with polycystic kidney disease. Which information should the nurse include in teaching during the first teaching session?

Options to consider for genetic counseling

What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects?

Oral low-dose aspirin therapy

When a patients intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider?

Oral temperature 101.6 F

A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities?

Place a pillow in the axilla when there is limited external rotation.

In monitoring a patient with increased intracranial pressure (ICP) who is mechanically ventilated, the nurse correlates which arterial blood gas value to effective management of the increased ICP?

PaCO2 32 mm Hg

A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurses best intervention for preventing injury?

Pad the side rails of the patients bed.

The nurse recognizes which finding as the earliest clinical manifestation of bladder cancer?

Painless hematuria

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should tNhe nRursIe exGpecBt w.iCll reMsult in new prescribed interventions?

Pale yellow urine output of 1200 mL over the past 2 hours.

The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit?

Parietal-occipital area

Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke?

Place needed objects on the patient's left side.

When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke?

Place objects needed for activities of daily living on the patients right side.

The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patients electronic record is most consistent with this diagnosis?

Patient demonstrates an absence of deep tendon reflexes.

After receiving change-of-shift report, which patient should the nurse assess first?

Patient who has just returned from having hemodialysis with a heart rate of 110/min.

When working in the urology/nephrology clinic, which patient's care could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/VN)?

Patient who will have catheterization to check for residual urine after voiding.

After change-of-shift report, which patient should the nurse assess first?

Patient with a urethral stricture who has not voided for 12 hours.

In the patient who develops complications related to a 5-cm calculi in the renal pelvis, the nurse prepares the patient for which emergent procedure?

Percutaneous nephrolithotomy

A client is admitted to the hospital with rightsided hemiplegia as a result of a stroke. To help prevent contractures, the nurse should employ which of the following interventions? (Select all that apply.)

Perform passive ROM to affected limbs at least twice a day after the first 24 hours. Support a completely flaccid arm with pillows when in bed or in a chair. Try placing the client in the prone position for 1530 minutes at a time. Use hightop tennis shoes or orthotics while in bed to prevent footdrop.

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care?

Perform range-of-motion (ROM) exercises every 4 hours.

The nurse is monitoring a patient with chronic kidney disease. Which findings should the nurse realize indicates fluid overload? (Select all that apply.)

Periorbital edema Crackles in the lungs Increased blood pressure

Which finding by the nurse for a patient admitted with glomerulonephritis indicates that treatment has been effective?

Peripheral and periorbital edema is resolved.

The nurse is reinforcing teaching about the most serious side effect of peritoneal dialysis with a patient scheduled for the first treatment. Which side effect should the patient state that indicates correct understanding?

Peritonitis.

To help prevent aspiration while feeding a patient who has a rightsided paralysis, the nurse includes which interventions? (Select all that apply.)

Place the patient in high Fowler's position. Instruct the patient to tilt the head and neck forward. Place food in the left side of the mouth. Avoid mixing foods with different textures.

A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?

Place the patient on a cardiac monitor.

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine?

Phenazopyridine may change the urine color.

Which information will the nurse monitor to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?

Phosphate level

Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?

Phosphate level

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brains surface?

Pia mater

The nurse is planning care for the patient with acute kidney injury. Which assessment data best supports the nursing diagnosis Excess Fluid Volume?

Pitting edema in the lower extremities

What intervention by the nurse would most encourage selffeeding in a patient who recently had a CVA with rightsided paralysis?

Place "finger foods" on the left side of the plate.

A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care?

Place a bedside commode close to the patient's bed.

A patient in the hospital has a history of functional urinary incontinence. Which nursing action will be included in the plan of care?

Place a bedside commode near the patients bed.

Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful?

Poached eggs, whole-wheat toast, and apple juice

The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patients siblings, parents, and grandparents. This assessment addresses the patients risk of what kidney disorder?

Polycystic Kidney Disease

During a home visit, the nurse is concerned that an older adult patient is developing chronic kidney disease. Because the patient has no history of cardiovascular disease, what data requires further consideration by the nurse?

Progressive edema

How will the nurse assess the flank area of a patient with pyelonephritis for tenderness?

Position one hand flat at the costovertebral angle (CVA) and strike it with the other fist.

In observing a new graduate nurse palpating a patient's kidneys during a physical examination, which observation requires an intervention by the nurse?

Positioning the other hand over the abdomen, above the ribcage

After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following?

Positioning to avoid hypoxia

A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take?

Provide discharge instructions about monitoring neurologic status.

The nurse contacts the healthcare provider with data collected from a patient admitted for a stroke. Which information indicates the patient may be experiencing central herniation? Select all that apply.

Posturing Bradycardia Positive Babinski reflex Increased systolic blood pressure

A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?

Prepare the patient for craniotomy.

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?

Prepare the patient for immediate craniotomy.

An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider should the nurse question?

Prepare the patient for lumbar puncture.

After a subarachnoid hemorrhage, the patients laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurses most appropriate action?

Prepare to administer 3% NaCl by IV as ordered.

A patient is scheduled for a CT scan of the abdomen with contrast. The patient has a baseline creatinine level of 2.3 mg/dL. In preparing this patient for the procedure, the nurse anticipates what orders?

Preprocedure hydration and administration of acetylcysteine

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

A patient has had diagnostic tests to assess uric acid levels. The tests reveal that levels are elevated. The nurse should consider the patient's intake of what to potentially explain excessive levels?

Protein

The nurse monitors the patient diagnosed with upper ureteral calculi with which clinical manifestation?

Radiating flank pain

In developing a teaching plan for a patient about treatment for bladder cancer, which data does the nurse include in the plan?

Radical cystectomy, combined with neoadjuvant chemotherapy, is considered to be the definitive treatment for bladder cancer.

In the patient with metabolic acidosis, what is the role of the kidneys in acid-base balance?

Reabsorbs bicarbonate ions

A patient with recurrent urinary tract infections has just undergone a cystoscopy and complains of slight hematuria during the first void after the procedure. What is the nurses most appropriate action?

Reassure the patient that this is not unexpected and then monitor the patient for further bleeding.

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.

Recent intracranial pathology Current anticoagulation therapy Symptom onset greater than 3 hours prior to admission

What should the nurse ask the patient about to determine possible causes of acute glomerulonephritis?

Recent sore throat and fever

The nurse is caring for a child suspected of having acute glomerulonephritis. When reviewing the data collected, the nurse is most likely to note what in the health history?

Recent upper respiratory infection

A patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect to find related to this illness?

Recent weight gain

An adult patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect?

Recent weight gain

A patient on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurses most recent assessments indicate that the patient is producing copious quantities of dilute urine. What is the nurses most appropriate response?

Recognize this as an expected finding.

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age- related changes. Of what phenomenon should the nurse be aware?

Reduction in cerebral blood flow

The patient with damage to which level of the spinal cord is at greatest risk of urinary incontinence?

S2-S4

A patient is scheduled for a diagnostic MRI of the lower urinary system. What pre-procedure education should the nurse include?

Relaxation techniques to apply during the test

A nurse is aware of the high incidence and prevalence of fluid volume deficit among older adults. What related health education should the nurse provide to an older adult?

Remember to drink frequently, even if you dont feel thirsty.

A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions?

Removing all metal-containing objects

A patient has experienced excessive losses of bicarbonate and has subsequently developed an acidbase imbalance. How will this lost bicarbonate be replaced?

Renal tubular cells will generate new bicarbonate.

The nurse is caring for a patient with a nursing diagnosis of deficient fluid volume. The nurses assessment reveals a BP of 98/52 mm Hg. The nurse should recognize that the patients kidneys will compensate by secreting what substance?

Renin

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

Report the BP and ICP to the health care provider.

A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

Report the BP and ICP to the health care provider.

After the insertion of an arteriovenous graft in the right forearm, a patient reports pain and coldness of the right fingers. Which action should the nurse take?

Report the patient's symptoms to the health care provider.

After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?

Report the patients symptoms to the health care provider.

A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurses best response to this assessment finding?

Report this to the physician as a possible sign of clinical deterioration.

A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patients abdomen is increasing in girth. What is the nurses most appropriate action?

Reposition the patient to facilitate drainage.

Which intervention will be included in the plan of care for a patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein?

Restrict physical activity to bed rest.

A patient with renal failure secondary to diabetic nephropathy has been admitted to the medical unit. What is the most life-threatening effect of renal failure for which the nurse should monitor the patient?

Retention of potassium

The patient with a rightsided paralysis from a stroke becomes frustrated with attempting to self feed. He throws the spoon at the nurse and begins to cry. What nursing actions would be best? (Select all that apply.)

Retrieve the spoon and sit quietly for a few seconds. Touch the patient and inquire if he would rather have a highprotein milkshake for his meal. Remind the patient that such behavior is not acceptable. Add an intervention to the NCP for increased support with selffeeding.

A patient with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acidbase balance?

Returning bicarbonate to the bodys circulation

Following a fall, a patient is brought to the emergency department. There was a brief loss of consciousness; the patient complains of headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area, and is currently having a seizure. The nurse prepares to care for this patient based on which evaluation of this assessment?

This is an emergency situation likely involving an epidural hematoma and requires surgery.

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

Temp 101.6

A male client is scheduled for radical bladder surgery for advanced cancer. He appears very anxious and is making sexually inappropriate jokes to the nursing staff. The most appropriate nursing diagnosis for this client is

Risk for Disturbed body image related to possible sexual dysfunction

For a client after nephrectomy and based on the location of the incision, the nurse would formulate the nursing diagnosis of

Risk for Injury: Postoperative Complications related to surgical procedure

Which nursing diagnosis is the priority in the patient diagnosed with chronic kidney disease?

Risk for Injury—Fractures

A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient?

Risk for aspiration related to inability to protect airway

The nurse is caring for a patient who had a brush biopsy 12 hours ago. The presence of what assessment finding should prompt the nurse to notify the physician?

Temperature 100.2F orally

A patient with a right temporal lobe hematoma is displaying Cheyne-Stokes respirations. How should this nurse interpret this assessment finding?

This patient requires surgical decompression of the brain.

The nurse has instructed a patient who is receiving hemodialysis about appropriate dietary choices. Which menu choice by the patient indicates that the teaching has been successful?

Scrambled eggs, English muffin, and apple juice

A patient with chronic kidney disease is very weak due to low hemoglobin. What should the nurse understand as the best explanation for the anemia?

Secretion of erythropoietin by the diseased kidney is reduced.

Which is the best position for the nurse to place a patient with increased intracranial pressure (ICP) and decreased intracranial compliance?

Semi-Fowler's with the neck in a neutral position

An 83yearold client is seen for urinary frequency and burning. A dipstick urine test reveals positive nitrates. Which action by the nurse is most appropriate?

Send the urine for a culture.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

Temperature of 101.4° F (38.6° C)

The nurse monitors for which diagnostic results in a patient with impaired renal function? Select all that apply.

Serum BUN 40 mg/dL Serum creatinine 1.8 mg/dL Serum phosphorus 5.2 mEq/L

In monitoring a patient's renal function, the nurse recognizes that aldosterone is released in response to which physiological factor?

Serum Sodium 130

The nurse correlates which lab result as the most reliable indicator of impaired renal function?

Serum creatinine 2.4 mg/dL

When the nurse is caring for a patient who has been admitted with a severe crushing injury after an industrial accident, which laboratory result will be most important to report to the health care provider?

Serum potassium level 6.5 mEq/L

The nurse correlates which data as placing a patient at risk for experiencing a metabolic seizure?

Serum sodium 115 mEq/L

A patient has a glomerular filtration rate of 20 mL/min. For which stage of renal failure should the nurse plan care for this patient?

Severe

Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome?

Short-term memory

The nurse is reinforcing teaching provided to a patient about risk factors for the development of bladder cancer. What risk factor should the patient state that indicates understanding of this teaching?

Smoking

The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants risks of renal carcinoma?

Smoking cessation

When planning meals for the patient with chronic kidney disease, which dietary choices are best for this patient?

Spaghetti and meat sauce, breadsticks

Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider?

Temperature of 101.5 F (38.6 C)

A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurses best answer?

Stop smoking as soon as possible

The nurse is caring for a patient who has renal calculi. Which action is essential for the nurse to take?

Strain all urine.

A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event?

Streptococcal infection

How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?

Strike a flat hand covering the costovertebral angle (CVA).

A client has received thrombolytic therapy for treatment of an ischemic stroke. Which intervention takes priority?

Stringent blood pressure control

The nurse is discussing alternative therapies with a patient who has had repeated urinary tract infections (UTIs) over the past year. The patient asks the nurse if there are any foods that might help her to potentially avoid developing more infections. What response by the nurse is most appropriate?

Studies show support for including vitamin C in the diet to help avoid urinary tract infections

You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patients labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults?

Substantially reduced renal function

Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patients plan of care?

Supervise the patients activities of daily living closely.

A patient admitted with bacterial meningitis and a temperature of 102 F (38.8 C) has orders for all of these collaborative interventions. Which action should the nurse take first?

Swap the nasopharyngeal mucosa for cultures.

The vital sign assessment of a person with a head injury was temperature (T), 97° F; pulse (P), 86; respiration (R), 18; and blood pressure (BP), 140/86 at 1:00. Which vital sign assessment made 30 minutes later is indicative of increasing intracranial pressure (ICP)?

T, 98° F; P, 78; R, 14; BP, 150/82

A client has a history of experiencing focal neurologic deficits, such as slurred speech and facial weakness, that last for a few hours at a time. The nurse then assesses this client for other possible manifestations of

TIA's

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient?

TPA infusion

The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education?

Take antihypertensive medication as ordered.

The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?

Taking a BP reading on the affected arm can damage the fistula.

The nurse is planning discharge instructions for a patient recovering from surgery to debulk a brain tumor. What is the rationale for teaching the patient about self-monitoring of capillary blood glucose level?

Taking steroid medication

The nurse monitors for which electrocardiogram change as the first indication of hyperkalemia in the patient with acute kidney disease?

Tall T waves

A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond?

Teach the family that emotional outbursts are common after strokes.

A 62-year-old asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan?

Teach the patient how to perform Kegel exercises.

The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?

Teaching the patient to perform deep breathing and coughing exercises

A female patient with a suspected urinary tract infection is to provide a clean-catch urine specimen for culture and sensitivity testing. What should the nurse do to obtain the specimen?

Tell the patient to clean the urethral area, void a small amount into the toilet, then void directly into a sterile container.

The emergency room nurse assessing clear drainage from the nose of a newly admitted patient with a head injury should perform which intervention?

Test fluid with a glucose AccuChek or Dextrostix.

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?

To avoid impeding venous outflow

The RN observes an LPN/LVN carrying out all of the following actions while caring for a patient with stage 2 chronic kidney disease. Which action requires the RN to intervene?

The LPN/LVN gives the iron supplement and phosphate binder with lunch.

A licensed practical/vocational nurse (LPN/VN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention?

The LPN/VN administers the iron supplement and phosphate binder with lunch.

Decerebrate posturing is present in an unconscious patient following a motor vehicle accident. The nurse expects to see which position?

The arms and legs are hyperextended, and arms are hyperpronated.

The nurse is preparing to discharge a patient with chronic kidney disease. In teaching the patient about calcium acetate tablets, which explanation by the nurse is best?

The calcium acetate will lower your serum phosphate levels

The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate?

The carotid endarterectomy involves surgical removal of plaque from an artery in the neck.

A client with a brain tumor is scheduled for a spiral CT scan. Which of these factors, if present in the client's history, would affect the nurse's preparation for the scan?

The client is allergic to seafood and iodine.

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?

The patient cleans the catheter while taking a bath every day.

A patient who is scheduled for an intravenous pyelogram (IVP) gives the nurse the following information. Which information has the most immediate implications for the patients care?

The patient describes allergies to shellfish and penicillin.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

The patient has atrial fibrillation and takes warfarin (Coumadin).

A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

The patient has atrial fibrillation and takes warfarin (Coumadin).

A rehabilitation nurse caring for a patient who has had a stroke is approached by the patients family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurses best answer?

The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible.

A patient diagnosed with a benign brain tumor is scheduled for gamma knife surgery. How would the nurse explain this procedure?

The gamma knife is a method of delivering a focused dose of radiation at your tumor.

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?

The patient has difficulty speaking.

The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?

The patient has difficulty talking.

A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?

The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability?

The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.

When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best?

The monitoring system helps show whether blood flow to the brain is adequate.

When the nurse is taking a history for a patient who is a possible candidate for a kidney transplant, which information about the patient indicates that the patient is not an appropriate candidate for transplantation?

The patient has metastatic lung cancer.

Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation?

The patient has metastatic lung cancer.

A patient who has had a transurethral resection with fulguration for bladder cancer 3 days previously calls the nurse at the urology clinic. Which information given by the patient is most important to report to the health care provider?

The patient has noticed clots in the urine.

Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider?

The patient has seen clots in the urine.

The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires rapid action by the nurse?

The patient is more difficult to arouse.

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse?

The patient is more difficult to arouse.

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN?

The nursing assistant goes into the patients room without a mask.

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?

The patient cleans the catheter while in the bathtub each day.

The patient was an unrestrained front-seat passenger in a motor vehicle crash and struck his forehead on the inside of the windshield. Diagnostic testing in the emergency department reveals coupcontrecoup injury. The nurse identifies which area as the contrecoup injury?

The posterior or occipital part of the brain

Following an intravenous pyelogram (IVP), all of the following assessment data are obtained. Which one requires immediate action by the nurse?

The respiratory rate is 38 breaths/minute.

The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

The staff nurse suctions the patient every 2 hours.

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

The staff nurse suctions the patient routinely every 2 hours.

The student nurse is attempting to irrigate an indwelling catheter. Which action by the student nurse best indicates an understanding of the correct procedure to employ?

The student nurse uses steady gentle pressure.

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)?

The urine may turn a reddish-orange color.

Which data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse?

There is a nontender lump in the axilla.

When teaching the patient with chronic kidney disease and hypertension to avoid salt substitute, the nurse bases this instruction on which rationale?

They can potentiate hyperkalemia.

The nurse caring for a patient who has just had an arteriovenous (AV) access created in his right forearm this morning should assess: (Select all that apply.)

a. for a bruit on auscultation of the AV site. b. capillary refill in the left hand. d. adequate elevation of the right arm. e. clotting of the AV access.

When assessing a patient with a possible stroke, the nurse finds that the patients aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question?

Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.

. A patient who is on hemodialysis for chronic kidney disease is prescribed sevelamer hydrochloride (Renagel) with meals. What explanation should be provided to the patient as the primary reason the medication is being given?

To prevent damage to bones from high phosphorus levels

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?

To remove atherosclerotic plaques blocking cerebral flow

The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider?

Urine output of 800 mL in the last hour

A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?

Urine output over an 8-hour period is 2500 mL.

Which information about a patient who was admitted 10 days previously with acute kidney injury (AKI) caused by dehydration will be most important for the nurse to report to the health care provider?

Urine output over an 8-hour period is 2500 mL.

Which parameter will be most important for the nurse to consider when titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation?

Urine output

A 48-yr-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma from a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon?

Urine output is 20 mL/hr for 2 hours.

A patient undergoes a nephrectomy after having massive trauma to the kidney. Which assessment finding obtained postoperatively is most important to communicate to the surgeon?

Urine output is 20 mL/hr for 2 hours.

The nurse outlines the agerelated changes that occur in the urinary system, which include:

a. hypertrophy of the prostate. decrease in secretion of renin. decrease in muscle tone of bladder.

In providing care to a patient with suspected urinary retention, the nurse prepares the patient for which diagnostic study?

Ultrasonic bladder scan

A patient with elevated BUN and creatinine values has been referred by her primary physician for further evaluation. The nurse should anticipate the use of what initial diagnostic test?

Ultrasound

A client who experienced a stroke that left residual left hemiplegia will not wash the left side or use her good limbs on the right to move or adjust the limbs on the left. The most appropriate diagnosis for this client is

Unilateral Neglect

A patient admitted to the medical unit with impaired renal function is complaining of severe, stabbing pain in the flank and lower abdomen. The patient is being assessed for renal calculi. The nurse recognizes that the stone is most likely in what anatomic location?

Ureter

The nurse correlates which physiological factor to the decreased risk of urinary tract infection in men compared with women?

Urethral length

The nurse prepares the patient with complaints of burning on urination for which diagnostic study?

Urinalysis

A nurse is preparing a patient diagnosed with benign prostatic hypertrophy (BPH) for a lower urinary tract cystoscopic examination. The nurse informs the patient that the most common temporary complication experienced after this procedure is what?

Urinary retention

A nurse is caring for a 73-year-old patient with a urethral obstruction related to prostatic enlargement. When planning this patients care, the nurse should be aware of the consequent risk of what complication?

Urinary tract infection

The nurse is caring for a patient who describes changes in his voiding patterns. The patient states, I feel the urge to empty my bladder several times an hour and when the urge hits me I have to get to the restroom quickly. But when I empty my bladder, there doesnt seem to be a great deal of urine flow. What would the nurse expect this patients physical assessment to reveal?

Urine retention

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is the priority?

Use an ultrasound scanner to check the postvoiding residual volume.

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes. Which nursing action is most appropriate?

Use an ultrasound scanner to check the postvoiding residual.

The nurse outlines the agerelated changes that occur in the urinary system, which include: (Select all that apply.)

a. hypertrophy of the prostate. decrease in secretion of renin. decrease in muscle tone of bladder.

The nurse is providing care to a patient at a local clinic. The nurse suspects that the patient is experiencing a urinary tract infection. Which urinalysis result supports the nurse's suspicions?

WBC 10-15

Which information from a patient's urinalysis requires that the nurse notify the health care provider?

WBC 20 to 26/hpf

When reviewing the results of a patients urinalysis, which information indicates that the nurse should notify the health care provider?

WBC: 20-26/hpf

The nurse monitors for which clinical manifestation in the patient with neurogenic shock?

Warm dry skin

The nurse is collecting data from a patient who has returned from a dialysis session. After dialysis, the nurse should anticipate which patient finding?

Weight loss

The care team is considering the use of dialysis in a patient whose renal function is progressively declining. Renal replacement therapy is indicated in which of the following situations?

When about 80% of the nephrons are no longer functioning

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke?

White male, age 60, with history of uncontrolled hypertension

The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time?

With each meal

A patient who has a kidney stone lodged in the ureter questions why it must be removed. What response by the nurse is most appropriate?

You may experience a condition known as hydronephrosis, which will result in increased pressure in your renal structures above the stone.

The nurse includes which statement in teaching a patient scheduled for intravenous urography?

You will need to increase fluid intake after this test."

When teaching a patient scheduled for a cystogram via a cystoscope about the procedure, the nurse tells the patient,

Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray.

A patient who has diabetic nephropathy asks the nurse, Why am I using smaller doses of insulin than I used to? What would be the best explanation by the nurse?

Your kidneys are no longer breaking down the insulin as much as before.

A client with oliguric ARF would exhibit

a BUN/creatinine ratio of 30:1.

A patient with an elevated blood urea nitrogen (BUN) and serum creatinine is scheduled for a renal arteriogram. The nurse should question an order from radiology for bowel preparation with the use of

a Fleet enema.

A client is admitted to the emergency department with severe, colicky pain that radiates to his bladder and scrotum. The nurse assesses these manifestations to be indicative of

a kidney stone in the ureter.

The nurse is reviewing the history and physical examination of a 22yearold man hospitalized for acute glomerulonephritis. The nurse recognizes the significant information of the probable etiology of this disease as:

a recent "strep throat" infection.

The nurse is reviewing the history and physical examination of a 22-year-old man hospitalized for acute glomerulonephritis. The nurse recognizes the significant information of the probable etiology of this disease as:

a recent strep throat infection.

The nurse is aware that the older adult is more at risk for a cranial bleed following a head injury because the older adult has:

a smaller brain, which allows for more movement inside the cranium.

The nurse is contributing to the plan of care for a patient who has chronic kidney disease. What possible effects of this condition should the nurse consider? (Select all that apply.)

a. Anemia b. Cardiac dysrhythmias c. Peripheral neuropathy e. Anorexia, nausea, vomiting

The nurse is collecting data from a patient with a vascular access graft in the right arm for dialysis. What should the nurse do when assessing this patient? (Select all that apply.)

a. Auscultate for a bruit over the site. b. Palpate for a thrill in the right arm.

The nurse is collecting the health history of a patient who has had multiple episodes of renal calculi formation. Which findings place the patient at an increased risk for the development of the renal calculi? (Select all that apply.)

a. Uric acid crystals in urine b. Frequent bacterial urinary infections c. Inadequate fluid intake d. Prolonged bed rest e. Tumor of parathyroid gland

The nurse is reinforcing teaching provided to a patient with chronic kidney disease who is receiving hemodialysis three times a week at a hemodialysis center. Which statements should be included? (Select all that apply.)

a. You may feel weak and fatigued after the treatment. b. You may not be able to eat before the treatment session. c. You will need to be weighed before and after the session. e. Report any numbness, swelling, redness, or drainage from the dialysis access site. f. You may experience some bleeding from the puncture site or a nosebleed. Report it if it doesnt stop within a few minutes.

A patient has been admitted to the acute care facility to rule out glomerulonephritis. Assessment findings that are supportive of the potential diagnosis include: (Select all that apply.)

a. flank pain. b. hematuria. c. periorbital edema. e. hypertension.

A client is complaining about the decrease in quality of life experienced since the client started dialysis. Using recent research to guide suggestions, the nurse counsels the client to

engage in regular exercise.

The nurse explains to a client's family that the most common overall manifestation of ARF is that

expected urine output is altered.

A client had a stroke. A nurse has arranged a consultation with an occupational therapist in order to enhance the client's ability to

feed himself

Acute renal artery obstruction would be suspected in a client if the nurse assessed sudden

flank pain over the affected kidney.

A patient who has increased blood urea nitrogen (BUN) and serum creatinine levels is scheduled for a renal arteriogram. Which bowel preparation order would the nurse question for this patient?

fleet enema

The nurse caring for a patient who has just had an arteriovenous (AV) access created in his right forearm this morning should assess: (Select all that apply.)

for a bruit on auscultation of the AV site. capillary refill in the left hand. adequate elevation of the right arm. clotting of the AV access.

The nurse reinforces explanations that the procedure for lithotripsy involves

fragmenting of stones by shock waves.

The assessment the nurse documents that supports the finding of apraxia would be the client's inability to

get dressed independently

Before palpating the bladder of a client with chronic urinary retention, the nurse should

get the bladder scanner to determine if the bladder is full.

. A client with stroke has a nursing diagnosis of Impaired Verbal Communication and has specific difficulty in verbal expression. The most helpful strategy by the nurse would be to

give the client practice in repeating words after the nurse.

The nurse explains that when the kidney suffers an autoimmune inflammatory reaction, the glomeruli lose their ability to function effectively, which leads to:

glomerulonephritis.

When assessing a 30-year-old man who complains of a feeling of incomplete bladder emptying and a split, spraying urine stream, the nurse asks about a history of

gonococcal urethritis.

Three months after a kidney transplant, a client develops fever, graft tenderness, malaise, and elevated white blood cell count. The nurse conducts further assessments based on understanding that the likely cause of these manifestations is

graft rejection

A client with a head injury has had the caloric test performed using icecold water. When the water was injected into the auditory canal, the client's eyes moved slowly toward the irrigated side and then quickly returned to midline. The nurse would conclude after watching this reaction that the client

has an intact brain stem.

To prevent the recurrence of renal calculi, the nurse teaches the patient to

have 2000 to 3000 mL of fluid a day.

A patient reports leg cramps during hemodialysis. What action should the nurse take?

infuse a bolus of NS

A patient complains of leg cramps during hemodialysis. The nurse should first

infuse a bolus of normal saline

A 72-yr-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?

insert urethral catheter

The most beneficial and safe positioning of an unconscious patient who has a rightsided closed head injury is:

head of bed 20 to 30 degrees.

The nurse assesses for the most common manifestations of a posttraumatic brain abscess, which are

headache and lethargy

The nurse is aware that a key sign of a brain tumor is:

headache that awakens the patient

A client has had two TIAs. Priority nursing actions focus on

helping the client reduce risk factors for stroke.

To assess the effect of epoetin alfa on a client with chronic renal failure, the nurse would monitor

hematocrit level.

A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication?

hemoglobin level 13

A nurse assessing a client with a renal abscess would expect to find

high fever

In a client with glomerulonephritis, the nurse would assess for the cardinal manifestation of

hypertension

The nurse is caring for a patient diagnosed with glomerulonephritis. The nurse notes that the patient is feeling confined with reports of feeling "bored and caged." During the interaction, the patient asks when he can resume his normal activities. The nurse clarifies that bed rest is enforced until:

hypertension and hematuria are gone.

The nurse is caring for a patient diagnosed with glomerulonephritis. The nurse notes that the patient is feeling confined with reports of feeling bored and caged. During the interaction, the patient asks when he can resume his normal activities. The nurse clarifies that bed rest is enforced until:

hypertension and hematuria are gone.

Which medication taken by a patient with decreased renal function will be of most concern to the nurse?

ibuprofen

During assessment of a patient with decreased renal function, which of these medications taken by the patient at home will be of most concern to the nurse?

ibuprofen (Motrin)

The nurse uses auscultation during assessment of the urinary system to

identify renal artery or aortic bruits.

When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect?

impaired judgement

As part of the care plan for a client with pyelonephritis, the nurse should

increase fluid intake to 3 to 4 L/day.