Test 3
Which of the following would the nurse prioritize as the most important action for the patient to take to prevent anaphylaxis?
Avoid potential allergens Strict avoidance of potential allergens is an important preventive measure for the patient at risk for anaphylaxis
The nurse is creating a discharge teaching plan for a patient with a latex allergy. Which of the following should be included? Select all that apply.
Avoidance of latex-based products Administration of antihistamines Administration of emergency epinephrine
Common tests of renal function include BUN, serum creatinine, creatinine clearance, and renal concentration tests.
Common tests of renal function include BUN, serum creatinine, creatinine clearance, and renal concentration tests.
A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?
"Are the burns associated with chemicals used in the plant?" If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff.
An investment banker with chronic renal failure informs the nurse of the choice for continuous cyclic peritoneal dialysis. Which is the best response by the nurse?
"This type of dialysis will provide more independence." Once a treatment choice has been selected by the client, the nurse should support the client in that decision. Continuous cyclic peritoneal dialysis will provide more independence for this client and supports the client's decision for treatment mode. The risk of peritonitis is greater, and symptoms should be discussed as part of the management of the disorder
A client with hyperparathyroidism is at risk for kidney stones
A client with hyperparathyroidism is at risk for kidney stones
A quick assessment technique is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's TBSA.
A quick assessment technique is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's TBSA.
According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%
According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%
After a kidney transplant, rejection and failure can occur within 24 hours (hyperacute), within 3 to 14 days (acute), or after many years. A hyperacute rejection is caused by an immediate antibody-mediated reaction that leads to generalized glomerular capillary thrombosis and necrosis
After a kidney transplant, rejection and failure can occur within 24 hours (hyperacute), within 3 to 14 days (acute), or after many years. A hyperacute rejection is caused by an immediate antibody-mediated reaction that leads to generalized glomerular capillary thrombosis and necrosis
A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:
After maintaining respirations, the most important immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis
Although the kidneys excrete excess water and nitrogen-based waste products of protein metabolism, persistent renal excretion of protein is not the function of kidneys, which are in the state of homeostasis
Although the kidneys excrete excess water and nitrogen-based waste products of protein metabolism, persistent renal excretion of protein is not the function of kidneys, which are in the state of homeostasis
Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?
Application of ice causes vasoconstriction and diminishes needed blood flow to the zone of injury
In a client with burns on the legs, which nursing intervention helps prevent contractures?
Applying knee splints prevents leg contractures by holding the joints in a position of function
Which of the following cell types are involved in humoral immunity?
B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity.
Common food causes of anaphylaxis include peanuts, tree nuts, shelfish, fish, milk, eggs, soy, and wheat
Common food causes of anaphylaxis include peanuts, tree nuts, shelfish, fish, milk, eggs, soy, and wheat
The nurse is caring for a patient with a medical history of untreated CKD that has progressed to ESKD. Which of the following serum values and associated signs and symptoms will the nurse expect the patient to exhibit? Select all that apply.
Calcium 7.5 mg/dL; hypotension and irritability Potassium 6.4 mEq/L; dysrhythmias and abdominal distention Phosphate 5.0 mg/dL; tachycardia and nausea and emesis Decreased calcium, increased potassium, and increased phosphate levels are associated with ESKD, along with the signs and symptoms associated with these serum values
Cardiac dysrhythmias and central nervous system complications are common among victims of electrical burns
Cardiac dysrhythmias and central nervous system complications are common among victims of electrical burns
During the acute phase of a burn, the nurse should assess the client's circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client's lifestyle and alcohol and tobacco use may be obtained later when the client's condition has stabilized.
During the acute phase of a burn, the nurse should assess the client's circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client's lifestyle and alcohol and tobacco use may be obtained later when the client's condition has stabilized.
Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure.
Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure.
Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV)
Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV)
The nurse is working with a patient who has had an allohematopoietic stem cell transplant (HSCT) and notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the patient has symptoms of which of the following?
Graft-versus-host disease Graft-versus-host disease is a major cause of morbidity and mortality in patients who have had allogeneic transplant. Clinical manifestation of the disease include diffuse rash that progresses to blistering and desquamation, and mucosal inflammation of the eyes and the entire GI tract with subsequent diarrhea, abdominal pain, and hepatomegaly.
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
Hypovolemic shock caused by hemorrhage If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience Hypovolemia
A child tips a pot of boiling water onto his bare legs. The mother should:
Immerse the child's legs in cool water. The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage.
Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.
Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.
Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated.
Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated.
The nurse is caring for a patient in the oliguric phase of acute kidney injury (AKI). What does the nurse know would be the daily urine output?
Less than 400ml The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 mL. In this phase, uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop.
A patient with severe combined immunodeficiency disease is receiving immunosuppression therapy to ensure engraftment of depleted bone marrow during transplantation procedures. What is the priority nursing care for this patient?
Meticulous infection control precautions Nursing care must be meticulous. Appropriate infection control precautions and thorough hand hygiene are essential
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?
The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician
Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.
Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.
Which type of immunity becomes active as a result of infection by a specific microorganism?
Naturally acquired active immunity occurs as a result of an infection by a specific microorganism
The term used to describe total urine output less than 0.5 mL/kg/hr is
Oliguria Oliguria is associated with acute and chronic renal failure. Anuria is used to describe total urine output less than 50 mL in 24 hours
On a hot day, the client found outside will be perspiring. When dehydration occurs, a client will have low urine output and increased specific gravity of urine
On a hot day, the client found outside will be perspiring. When dehydration occurs, a client will have low urine output and increased specific gravity of urine
Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.
Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.
A client undergoes renal angiography. The nurse prepares the client for the test and provides postprocedure care. Which intervention should the nurse provide to the client after renal angiography?
Palpate the pulses in the legs and feet To observe for signs of arterial occlusion in a client who has undergone renal angiography, the nurse should palpate the pulses in the legs and feet. While preparing the client for renal angiography, the nurse asks the client to void
When assessing the impact of medications on the etiology of acute renal failure, the nurse recognizes which of the following as the drug that is not nephrotoxic?
Penicillin
Penicillin is the most common cause of anaphylaxis and accounts for about 75% of fatal anaphylactic reactions in the United States each year
Penicillin is the most common cause of anaphylaxis and accounts for about 75% of fatal anaphylactic reactions in the United States each year
Which instruction is the most important to give a client who has recently had a skin graft?
Protect the graft from direct sunlight. To prevent burning and sloughing, the nurse must instruct the client to protect the graft from direct sunlight
A nurse is aware of the need to assess patients' risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
Radiocontrast agents present a significant threat of anaphylaxis in the hospital setting
A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?
Related to circumferential eschar As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility
A client presents to the emergency department complaining of a dull, constant ache along the right costovertebral angle along with nausea and vomiting. The most likely cause of the client's symptoms is:
Renal calculi usually presents as a dull, constant ache at the costovertebral angle. The client may also present with nausea and vomiting, diaphoresis, and pallor
One of the roles of the nurse in caring for clients with chronic renal failure is to help them learn to minimize and manage potential complications. This would include:
Restrict sources of potassium usually found in fresh fruits and vegetables; hyperkalemia can cause life-threatening changes.
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?
Risk for infection The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body
Silver nitrate 0.5% does not penetrate eschar.
Silver nitrate 0.5% does not penetrate eschar.
Tachycardia, slight hypotension, and anxiety are expected soon after the burn.
Tachycardia, slight hypotension, and anxiety are expected soon after the burn.
The client with pruritus needs to keep the skin clean and dry. The client should take brief showers with tepid water, pat the skin dry, use moisturizing lotions or creams, and avoid scratching. In addition, the client should use a mild laundry detergent to wash clothes and an extra rinse cycle to remove all detergent or add 1 tsp vinegar per quart of water to the rinse cycle to remove any detergent residue.
The client with pruritus needs to keep the skin clean and dry. The client should take brief showers with tepid water, pat the skin dry, use moisturizing lotions or creams, and avoid scratching. In addition, the client should use a mild laundry detergent to wash clothes and an extra rinse cycle to remove all detergent or add 1 tsp vinegar per quart of water to the rinse cycle to remove any detergent residue.
The diagnosis of anaphylaxis risk is determined by prick and intradermal skin testing. Skin testing of patients who have clinical symptoms consistent with a type I, IgE-mediated reaction has been recommended
The diagnosis of anaphylaxis risk is determined by prick and intradermal skin testing. Skin testing of patients who have clinical symptoms consistent with a type I, IgE-mediated reaction has been recommended
The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. A 1-kg weight gain is equal to 1,000 mL of retained fluid.
The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. A 1-kg weight gain is equal to 1,000 mL of retained fluid.
The nurse cares for a client with a right-arm arteriovenous fistula (AVF) for hemodialysis treatments. Which nursing action is contraindicated?
The nurse assesses the vascular access for patency. The bruit, or "thrill," over the venous access site must be evaluated at least every shift. The nurse takes precautions to ensure that the extremity with the vascular access is not used for measuring blood pressure or for obtaining blood specimens; tight dressings, restraints, or jewelry over the vascular access must be avoided as well.
The nurse is correct to assess the kidneys for tenderness at the costovertebral angle
The nurse is correct to assess the kidneys for tenderness at the costovertebral angle
The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation process, typically speaks to family members about organ donation and answers their questions. Contact is permitted after the procedure with consent from the donor's family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers.
The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation process, typically speaks to family members about organ donation and answers their questions. Contact is permitted after the procedure with consent from the donor's family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers.
The upper urinary tract is composed of the kidneys, renal pelvis, and ureters. The lower urinary tract consists of the bladder, urethra, and pelvic floor muscles.
The upper urinary tract is composed of the kidneys, renal pelvis, and ureters. The lower urinary tract consists of the bladder, urethra, and pelvic floor muscles.
To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator, as ordered. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications do not relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client
To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator, as ordered. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications do not relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client
To self-administer epinephrine, the client should remove the autoinjector from its carrying tube, grasp the unit with the black tip (injectiing end) pointed downward, form a fist around the device, and remove the gray safety release cap. Then the client should hold the black tip near the outer thigh and swing and jab firmly into the outer thigh at a 90-degree angle until a click is heard. Next, the client should hold the device firmly in place for about 10 seconds, remove the device, and massage the site for about 10 seconds.
To self-administer epinephrine, the client should remove the autoinjector from its carrying tube, grasp the unit with the black tip (injectiing end) pointed downward, form a fist around the device, and remove the gray safety release cap. Then the client should hold the black tip near the outer thigh and swing and jab firmly into the outer thigh at a 90-degree angle until a click is heard. Next, the client should hold the device firmly in place for about 10 seconds, remove the device, and massage the site for about 10 seconds.
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Urine output of 20 ml/hour Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification
When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal
When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal
When fluid intake decreases, specific gravity normally increases. With high fluid intake, specific gravity decreases. Disorders or conditions that cause decreased urine-specific gravity include diabetes insipidus, glomerulonephritis, and severe renal damage. Disorders that can cause increased specific gravity include diabetes, nephritis, and fluid deficit.
When fluid intake decreases, specific gravity normally increases. With high fluid intake, specific gravity decreases. Disorders or conditions that cause decreased urine-specific gravity include diabetes insipidus, glomerulonephritis, and severe renal damage. Disorders that can cause increased specific gravity include diabetes, nephritis, and fluid deficit.