...
A client has a history of renal calculi. Which statement by the client indicates a good understanding of preventive measures? a. I know I should drink at least 3 to 4 liters of fluid every day. b. I cant eat much dairy or other sources of calcium. c. Aspirin and aspirin-containing products can lead to stones. d. The doctor will give me antibiotics at the first sign of a stone.
A
16. Know the risk factors/conditions for the formation of intracardiac thrombi A patient who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the patient's health history creates a heightened risk of intracardiac thrombi? A) Atrial fibrillation B) Infective endocarditis C) Recurrent pneumonia D) Recent surgery
A
65. The nurse is assessing a client with numerous areas of bruising. Which question does the nurse ask to determine the cause of this finding? a. Do you take aspirin? b. How often do you exercise? c. Are you a vegetarian? d. How often do you take Tylenol?
A
A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurse's best action? A) Rapidly assess the patient's cardiopulmonary status. B Arrange for an ECG. C)Increase the height of the patient's bed. D) Manage the patient's anxiety.
A
A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority? a. Apply oxygen and continuous pulse oximetry. b. Allow the client to suck on small quantities of ice chips. c. Request an antitussive medication from the physician. d. Have the respiratory therapist provide humidified room air.
A
A client who had kidney trauma required a nephrectomy. What does the nurse teach the client about this condition? a. You need to avoid participating in contact sports like football. b. You probably will end up on dialysis a few years from now. c. You need medication to control your high blood pressure from the injury. d. You will always be required to restrict your salt and fluid intake.
A
A client with a renal calculus has just returned from an extracorporeal shock wave lithotripsy procedure, and the nurse finds an ecchymotic area on the clients right lower back. Which is the nurses priority intervention? a. Notify the health care provider. b. Apply ice to the site. c. Place the client in the prone position. d. Document the observation in the chart.
A
A female patient has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the patient, the nurse should address what topic? A) The risk of developing a vaginal yeast infection as a consequent of antibiotic therapy B) The need to expect a heavy menstrual period following the course of antibiotics C) The risk of developing antibiotic resistance after the course of antibiotics D) The need to undergo a series of three urine cultures after the antibiotics have been completed
A
A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? a. The client has lost 11 pounds in the past 10 days. b. The clients urine specific gravity is 1.048. c. No blood is observed in the clients urine. d. The clients blood pressure is 152/88 mm Hg.
A
A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela? A) Stroke B) Myocardial infarction (MI) C) Hemorrhage D) Peripheral edema
A
A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action? A) Inform the physician and assess the patient for signs of infection. B) Flush the peritoneal catheter with normal saline. C) Remove the catheter promptly and have the catheter tip cultured. D) Administer a bolus of IV normal saline as ordered.
A
A nurse is caring for a 73-year-old patient with a urethral obstruction related to prostatic enlargement. When planning this patient's care, the nurse should be aware of the consequent risk of what complication? A) Urinary tract infection B) Enuresis C) Polyuria D) Proteinuria
A
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the clients hands. d. Sedate the client immediately.
A
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? A) Increased fluid intake following the test B) Use of an OTC diuretic after the test C) Gentle massage of the lower abdomen D) Activity limitation for the first 12 hours after the test
A
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? A) In the ureteropelvic junction B) In the ureteral segment near the sacroiliac junction C) In the ureterovesical junction D)
A
A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A) Implementation of infection-control measures B) Close monitoring of skin integrity and color C) Frequent assessment of the patient's psychosocial status D) Administration of antiretroviral medications
A
A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A) Have the patient refrain from food and fluids after midnight. B) Administer the contrast agent orally 10 to 12 hours before the study. C) Administer the radioactive agent intravenously the evening before the study. D) Encourage the intake of 64 ounces of water 8 hours before the study.
A
A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia B) Referred pain C) Cellulitis D) Venous thromboembolism (VTE)
A
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A) To remove air from the pleural space B) To drain copious sputum secretions C) To monitor bleeding around the lungs D) To assist with mechanical ventilation
A
A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient's post-procedure care? A) Strain the patient's urine following the procedure. B) Administer a bolus of 500 mL normal saline following the procedure. C) Monitor the patient for fluid overload following the procedure. D) Insert a urinary catheter for 24 to 48 hours after the procedure.
A
An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A) Administer IV fluids B) Administer broad-spectrum antibiotics C) Administer IV potassium chloride D) Administer packed red blood cells
A
An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patient's plan of care? A) Suction the patient's airway secretions. B) Immobilize the ribs with an abdominal binder. C) Prepare the patient for surgery. D) Immediately sedate and intubate the patient.
A
Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following? A) Perform at least 100 chest compressions per minute. B) Pause to allow a colleague to provide a breath every 10 compressions. C) Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes. D) Perform high-quality chest compressions as rapidly as possible.
A
During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A) Following proper hand-washing techniques B) Avoiding chemicals that are toxic to the liver C) Wearing a condom during sexual contact D) Limiting alcohol intake
A
It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurses priority action? a. Monitor the clients oxygenation. b. Teach the client about potential side effects. c. Monitor the IV insertion site. d. Monitor for bleeding.
A
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? A) Heart failure B) Glomerulonephritis C) Ureterolithiasis D) Aminoglycoside toxicity
A
The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A) 20 cm H2O B) 15 cm H2O C) 10 cm H2O D) 5 cm H2O
A
The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A) Stable vital signs and ABGs B) Pulse oximetry above 80% and stable vital signs C) Stable nutritional status and ABGs D) Normal orientation and level of consciousness
A
The nurse and urologist have both been unsuccessful in catheterizing a patient with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the physician using to drain the patient's bladder? A) Insertion of a suprapubic catheter B) Scheduling the patient immediately for a prostatectomy C) Application of warm compresses to the perineum to assist with relaxation D) Medication administration to relax the bladder muscles and reattempting catheterization in 6 hours
A
The nurse assesses a clients chest tube and finds continuous bubbling in the water seal chamber. When the nurse clamps the chest tube close to the clients dressing, the bubbling stops. How does the nurse interpret this finding? a. An air leak is present at the chest tube insertion site or in the thoracic cavity. b. An air leak is present in the drainage system. c. More water needs to be added to the water seal. d. The system is functioning appropriately and no intervention is needed.
A
The nurse completes which assessment in a client with acute glomerulonephritis and periorbital edema? a. Auscultating breath sounds b. Checking blood glucose levels c. Measuring deep tendon reflexes d. Testing urine for protein
A
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? A) Maintain aseptic technique when administering dialysate. B) Wash the skin surrounding the catheter site with soap and water prior to each exchange. C) Add antibiotics to the dialysate as ordered. D) Administer prophylactic antibiotics by mouth or IV as ordered.
A
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? A) Maintain aseptic technique when administering dialysate. B) Wash the skin surrounding the catheter site with soap and water prior to each exchange. C) Add antibiotics to the dialysate as ordered. D) Administer prophylactic antibiotics by mouth or IV as ordered.
A
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? A) Hematuria B) Precipitous decrease in serum creatinine levels C) Hypotension unresolved by fluid administration D) Glucosuria
A
The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis
A
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? A) Assessment of the quantity of the patient's urine output B) Assessment of the patient's incision C) Assessment of the patient's abdominal girth D) Assessment for flank or abdominal pain
A
The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurse's 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 nurse's best response? A) Assess the patient for signs of bleeding and inform the physician. B) Monitor the patient's vital signs every 15 minutes for the next hour. C) Reposition the patient and reassess vital signs. D) Palpate the patient's flank for pain and inform the physician.
A
The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed? A) Ensure that suction apparatus is set up at the bedside. B) Pad the patient's bed rails. C) Maintain bed rest whenever possible. D) Provide several small meals each day.
A
The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds
A
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) A vein and an artery in your arm will be attached surgically. B) The arm should be immobilized for 4 to 6 days. C) One needle will be inserted into the fistula for each dialysis treatment. D) The fistula can be used 2 days after the surgery for dialysis treatment.
A
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? A) Increased fluid intake to produce a full bladder B) IV administration of radiopaque contrast agent C) Sedation and intubation D) Injection of a radioisotope
A
The nurse is working with a patient who has been experiencing episodes of urinary retention. What assessment finding would suggest that the patient is experiencing retention? A) The patients suprapubic region is dull on percussion. B) The patient is uncharacteristically drowsy. C) The patient claims to void large amounts of urine 2 to 3 times daily. D) The patient takes a beta adrenergic blocker for the treatment of hypertension.
A
The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patient's risk of developing pulmonary emboli (PE)? A) Early ambulation B) Increased dietary intake of protein C) Maintaining the patient in a supine position D) Administering aspirin with warfarin
A
What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation? a. Ask the client to point to words on a board. b. Ask the client to blink for yes and no. c. Have the client mouth words slowly. d. Teach the client some simple sign language.
A
When the ED nurse receives a radio call from an ambulance transporting a client who sustained chest trauma and has a severe flail chest, the nurse would set up the treatment area with a. an intubation tray. b. petroleum jelly gauze. c. a pulse oximeter. d. rib spreaders.
A
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 patient's 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. E) The cuffs absorb dialysate
ABCD
A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patient's diet to maximize the therapeutic effect and minimize the risks of complications. The patient's diet should include which of the following modifications? Select all that apply. A) Decreased protein intake B) Decreased sodium intake C) Increased potassium intake D) Fluid restriction E) Vitamin D supplementation
ABD
A patient's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply. A) "How many alcoholic drinks do you typically consume in a week?" B) "Have you ever been tested for diabetes?" C) "Have you ever been diagnosed with gallstones?" D) "Would you say that you eat a particularly high-fat diet?" E) "Does anyone in your family have cystic fibrosis?"
AC
A client who had a liver transplant a month ago is admitted with fever and tachycardia. Which medication does the nurse prepare to administer to this client? a. Ceftriaxone (Rocephin) b. Cyclosporine (Sandimmune) c. Azithromycin (Zithromax) d. Ribavirin (Copegus)
B
31. 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? A) The decision is certainly yours to make, but be sure not to make a mistake. B) Kidney transplants in patients your age are as successful as they are in younger patients. C) I understand your hesitancy to commit to a transplant surgery. Success is comparatively rare. D) Have you talked this over with your family?
B
A client is 12 hours postkidney transplantation. The nurse notes that the client has put out 2000 mL of urine in 10 hours. Which assessment does the nurse carry out first? a. Skin turgor b. Blood pressure c. Serum blood urea nitrogen (BUN) level d. Weight of the client
B
A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? a. Warm the dialysate solution in a microwave before instillation. b. Take a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.
B
A client who underwent liver transplantation 2 weeks ago reports a temperature of 101 F (38.3 C) and right flank pain. Which is the nurses best response? a. The anti-rejection drugs you are taking made you susceptible to infection. b. You should go to the hospital immediately to have your new liver checked out. c. You should take an additional dose of cyclosporine today. d. Take acetaminophen (Tylenol) every 4 hours until you feel better.
B
A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A) Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C) Increased BP with narrowed pulse pressure D) Sudden diaphoresis
B
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.
B
A patient is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the patient's oxygenation status at the bedside? A. Obtain serial ABG samples. B. Monitor pulse oximetry readings. C. Test pulmonary function. D. Monitor incentive spirometry volumes.
B
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) A fasting serum potassium level and a random urine sample B) A 24-hour urine specimen and a serum creatinine level midway through the urine collection process C) A BUN and serum creatinine level on three consecutive mornings D) A sterile urine specimen and an electrolyte panel, including sodium, potassium, calcium, and phosphorus values
B
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room
B
A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected outcome of this treatment? A) Reduction in the appearance of new lesions on the MRI B) Decreased muscle spasms in the lower extremities C) Increased muscle strength in the upper extremities D) Decreased severity and duration of exacerbations
B
A patient has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the patient's discharge education accordingly. What preventative measure should the nurse encourage the patient to adopt? A) Increasing intake of protein from plant sources B) Increasing fluid intake C) Adopting a high-calcium diet D) Eating several small meals each day
B
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? A) Imbalanced nutrition: More than body requirements B) Excess fluid volume C) Sedentary lifestyle D) Adult failure to thrive
B
A patient on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurse's most recent assessments indicate that the patient is producing copious quantities of dilute urine. What is the nurse's most appropriate response? A) Assess the patient for further signs or symptoms of rejection. B) Recognize this as an expected finding. C) Inform the primary care provider of this finding. D) Administer exogenous antidiuretic hormone as ordered.
B
A patient with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the patient's plan of care? A) Impaired physical mobility related to presence of an indwelling urinary catheter B) Risk for infection related to presence of an indwelling urinary catheter C) Toileting self-care deficit related to urinary catheterization D) Disturbed body image related to urinary catheterization
B
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 patient's abdomen is increasing in girth. What is the nurse's most appropriate action? A) Advance the catheter 2 to 4 cm further into the peritoneal cavity. B) Reposition the patient to facilitate drainage. C) Aspirate from the catheter using a 60-mL syringe. D) Infuse 50 mL of additional dialysate.
B
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? A) Accumulation of wastes B) Retention of potassium C) Depletion of calcium D) Lack of BP control
B
A patient with thoracic trauma is admitted to the ICU. The nurse notes the patient's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A) A chest tube B) A tracheostomy C) An endotracheal tube D) A feeding tube Ans:
B
A patient's electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis? A) Leukemia B) Hemophilia C) Hypoproliferative anemia D) Hodgkin's lymphoma
B
The critical care nurse is monitoring the patient's urine output and drains following renal surgery. What should the nurse promptly report to the physician? A) Increased pain on movement B) Absence of drain output C) Increased urine output D) Blood-tinged serosanguineous drain output
B
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) A patient with a history of polycystic kidney disease B) A patient with diabetes mellitus and poorly controlled hypertension C) A patient who is morbidly obese with a history of vascular disorders D) A patient with severe chronic obstructive pulmonary disease
B
The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately? a. Respiratory rate of 28 breaths/min b. Urinary output of 10 mL/hr c. Heart rate of 100 beats/min d. Dry cough
B
The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day? A) 1,250 mL B) 2,000 mL C) 2,750 mL D) 3,500 mL
B
The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? A) How to milk the chest tubing B) How to splint the incision when coughing C) How to take prophylactic antibiotics correctly D) How to manage the need for fluid restriction
B
The nurse is completing the preoperative checklist on a client. The client states, I take an aspirin every day for my heart. How does the nurse respond? a. I will call your doctor and request a prescription for pain medication. b. I need to call the surgeon and reschedule your surgery. c. Ill give you the prescribed Tylenol to minimize any headache before surgery. d. I need to administer vitamin K to prevent bleeding during the procedure.
B
The nurse is planning the care of a patient with hyperthyroidism. What should the nurse specify in the patient's meal plan? A) A clear liquid diet, high in nutrients B) Small, frequent meals, high in protein and calories C) Three large, bland meals a day D) A diet high in fiber and plant-sourced fat
B
What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. A. Mediastinal chest tube system B. Dry suction chest tube system C. Wet suction chest tube system D. Dry-Wet suction chest tube system
B
When providing care for a client receiving peritoneal dialysis, the nurse notices that the effluent is cloudy. Which intervention is most important for the nurse to carry out? a. Irrigate the peritoneal catheter with saline. b. Send a specimen for culture and sensitivity. c. Document the finding in the clients chart. d. Change the dialysate solution and catheter tubing.
B
A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.
C
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? A) Hypokalemia B) Hypocalcemia C Dehydration D) Acute flank pain
C
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient? A) All at one time, to provide a longer rest period B) Before meals, to stimulate her appetite C) In the morning, with frequent rest periods D) Before bedtime, to promote rest
C
A patient has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the patient's chronic kidney disease is at what stage? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4
C
A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy? A) The patient's diet should be low protein with ample fat. B) The patient may experience short-term changes in cognition. C) The patient is at an increased risk for developing infection. D) The patient is at a decreased risk for development of thrombophlebitis and thromboembolism.
C
A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the patient's bleeding and established that his vital signs are stable. What should be the nurse's next action? A) Position the patient in a prone position to minimize bleeding. B) Establish IV access for the administration of vitamin K. C) Prepare for the administration of factor VIII. D) Administer a normal saline bolus to increase circulatory volume.
C
An older client is hospitalized with suspected heart failure. After 2 days of treatment, the client is not improving. Which laboratory value does the nurse report to the provider? a. Potassium, 3.7 mEq/L b. Sodium, 144 mEq/L c. Glomerular filtration rate, 55 mL/min d. Creatinine, 0.9 mg/dL
C
Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication? A) Pulmonary edema B) Pericardiocentesis C) Cardiac tamponade D) Pericarditis
C
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? A) Diabetes insipidus B) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) C) Diabetes mellitus D) Renal carcinoma
C
Results of a patient's 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? A) The patient's kidneys are capable of maintaining acid-base balance. B) The patient's kidneys reabsorb most of the potassium that the patient ingests. C) The patient's kidneys can produce sufficiently concentrated urine. D) The patient's kidneys are producing sufficient erythropoietin.
C
The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side. What finding requires immediate attention? a. Pain at the chest tube insertion site b. Fluctuation in the water seal chamber with breathing c. Puffiness of the skin around the chest tube insertion site and a crackling feeling d. Dullness to percussion on the affected side
C
The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The clients oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse? a. Encourage the client to take deep, controlled breaths. b. Document findings and continue to monitor the client. c. Notify the health care provider and prepare for intubation. d. Stabilize the chest wall with rib binders.
C
The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which nursing intervention has the greatest priority when a dialysis exchange is performed? a. Adding potassium and antibiotic to the dialysate bags b. Positioning the client on either side c. Using sterile technique when hooking up dialysate bags d. Warming the dialysate fluid in a microwave oven
C
The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurses best action? a. Change the clients position. b. Suction the client. c. Assess lung sounds. d. Turn off the pressure alarm.
C
The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)? A) Hypernatremia B) Hypomagnesemia C) Hyperkalemia D) Hypercalcemia
C
The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions? A) Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B) Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months C) Promoting communication with the patient and family along with addressing end-of-life issues D) Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea
C
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? A) Using a stethoscope for auscultating the fistula is contraindicated. B) The patient feels best immediately after the dialysis treatment. C) Taking a BP reading on the affected arm can damage the fistula. D) The patient should not feel pain during initiation of dialysis.
C
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? A) Potassium and sodium B) Bicarbonate and urea C) Glucose and protein D) Creatinine and chloride
C
The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurse's assessment reveals that the stoma is a dark purplish color. What is the nurse's most appropriate response? A) Document the presence of a healthy stoma. B) Assess the patient for further signs and symptoms of infection. C) Inform the primary care provider that the vascular supply may be compromised. D) Liaise with the wound-ostomy-continence (WOC) nurse because the ostomy appliance around the stoma may be too loose
C
The nurse is caring for a patient with a nursing diagnosis of deficient fluid volume. The nurse's assessment reveals a BP of 98/52 mm Hg. The nurse should recognize that the patient's kidneys will compensate by secreting what substance? A) Antidiuretic hormone (ADH) B) Aldosterone C) Renin D) Angiotensin
C
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)? A) The patient is complains of an inability to initiate voiding. B) The patient's urine is cloudy with a foul odor. C) The patient's average urine output has been 10 mL/hr for several hours. D) The patient complains of acute flank pain.
C
The nurse is teaching a patient that the body needs iodine for the thyroid to function. What food would be the best source of iodine for the body? A) Eggs B) Shellfish C) Table salt D) Red meat
C
Which dietary modification does the nurse provide for a client with hyperthyroidism? a. Decreased calories and proteins and increased carbohydrates b. Elimination of carbohydrates and increased proteins and fats c. Increased calories, proteins, and carbohydrates d. Supplemental vitamins and reduction of calories
C
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist in planning a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.
C
1. Know nursing interventions when caring for patients on mechanical ventilation: Focus on preventing trauma and infection The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A) Keep the patient in a low Fowler's position. B) Perform tracheostomy care at least once per day. C) Maintain continuous bedrest. D) Monitor cuff pressure every 8 hours.
D
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? A) Psychosocial stress B) Hypersensitivity to an immunization C) Menarche D) Streptococcal infection
D
A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a. Administer oxygen and reassess. b. Auscultate the clients lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.
D
A client with glomerulonephritis has a glomerular filtration rate (GFR) of 40 mL/min, as measured by a 24-hour creatinine clearance. Which is the nurses interpretation of this finding? a. Excessive GFR, client at risk for dehydration b. Excessive GFR, client at risk for fluid overload c. Reduced GFR, client at risk for dehydration d. Reduced GFR, client at risk for fluid overload
D
A clients urine specific gravity is 1.040. Which action by the nurse is best? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Review the clients creatinine level. d. Increase the clients fluid intake.
D
A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the clients blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take? a. Position the client to lay on the surgical incision. b. Measure the specific gravity of the clients urine. c. Administer intravenous pain medications. d. Assess the rate and quality of the clients pulse
D
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.
D
A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? A) Maintaining positive chest-wall pressure B) Monitoring pleural fluid osmolarity C) Providing positive intrathoracic pressure D) Removing excess air and fluid
D
A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patient's care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? A) Constipation related to immobility B) Risk for injury related to altered thought processes C) Hyperthermia related to the inflammatory process D) Excess fluid volume related to generalized edema
D
A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis? A) Position the patient supine to facilitate diaphragm movement. B). Administer corticosteroids by nebulizer as ordered. C) Perform oral suctioning as needed to remove secretions. D) Maintain the patient in a semi-Fowler's position whenever possible.
D
A patient is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The patient is quickly learning to self-manage the urinary diversion, but expresses concern about the presence of mucus in the urine. What is the nurses most appropriate response? A) Report this finding promptly to the primary care provider. B) Obtain a sterile urine sample and send it for culture. C) Obtain a urine sample and check it for pH. D) Reassure the patient that this is an expected phenomenon.
D
A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient? A) Assure the patient that everything will be all right and that remaining calm is the best strategy. B) Ask a family member to interpret what the patient is trying to communicate. C) Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely. D) Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board.
D
A patients most recent laboratory findings indicate a glomerular filtration rate (GFR) of 58 mL/min. The nurse should recognize what implication of this diagnostic finding? A) The patient is likely to have a decreased level of blood urea nitrogen (BUN). B) The patient is at risk for hypokalemia. C) The patient is likely to have irregular voiding patterns. D) The patient is likely to have increased serum creatinine levels.
D
In assessing a client 6 hours after a radical nephrectomy for renal cell carcinoma, the nurse notes that the clients blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which is the nurses best action? a. Position the client so that the remaining kidney is not dependent. b. Measure the specific gravity of the clients urine. c. Document the findings in the clients record. d. Assess the pulse rate and quality, and then notify the provider.
D
In assessing a client recently diagnosed with acute glomerulonephritis, the nurse asks which question to determine potential contributing factors? a. Are you sexually active? b. Do you have pain or burning on urination? c. Has anyone in your family had chronic kidney problems? d. Have you had a cold or sore throat within the last 2 weeks?
D
The RN has assigned a client with a newly placed arteriovenous (AV) fistula in the right arm to an LPN. Which information about the care of this client is most important for the RN to provide to the LPN? a. Avoid movement of the right extremity. b. Place gentle pressure over the fistula site after blood draws. c. Start any IV lines below the site of the fistula. d. Take blood pressure in the left arm.
D
The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm? A) Pulseless electrical activity (PEA) B) Ventricular fibrillation C) Ventricular tachycardia D) Asystole
D
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? A) When the patient's creatinine level drops below 1.2 mg/dL (110 mmol/L) B) When the patient's blood urea nitrogen (BUN) is above 15 mg/dL C) When approximately 40% of nephrons are not functioning D) When about 80% of the nephrons are no longer functioning
D
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? A) When the patient's creatinine level drops below 1.2 mg/dL (110 mmol/L) B) When the patient's blood urea nitrogen (BUN) is above 15 mg/dL C) When approximately 40% of nephrons are not functioning D) When about 80% of the nephrons are no longer functioning
D
The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP). What intervention is most appropriate for this client? a. Administering antianxiety medications PRN b. Administering a medication to help the client sleep c. Telling the client to relax and let the ventilator do the work d. Making sure the client is breathing spontaneously
D
The nurse is caring for a patient who has a fluid volume deficit. When evaluating this patient's urinalysis results, what should the nurse anticipate? A) A fluctuating urine specific gravity B) A fixed urine specific gravity C) A decreased urine specific gravity D) An increased urine specific gravity
D
When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding? A) A diastolic blood pressure that is lower during exhalation B) A diastolic blood pressure that is higher during inhalation C) A systolic blood pressure that is higher during exhalation D) A systolic blood pressure that is lower during inhalation
D
