230 Med Surg Final Review 4/4

At a health fair, the nurse is teaching attendees about acute kidney injury (AKI). What statement made by a participant indicates a need for further teaching? "The onset of AKI is sudden." "AKI is usually not reversible." "AKI involves 50 percent of nephrons." "Duration of AKI is around 2 to 3 weeks."

"AKI is usually not reversible." (This response requires further teaching, because AKI is reversible in many cases after identifying the underlying cause. The onset of AKI is sudden and involves around 50 percent of nephrons. The duration of AKI is around 2 to 3 weeks and is usually less than 3 months.)

The nurse wishes to reduce the incidence of hospital-acquired acute kidney injury. Which question by the nurse to the interdisciplinary health care team will result in reducing client exposure? "Would we filter air circulation?" "Can we use less radiographic contrast dye?" "Would we add low-dose dobutamine?" "Can we decrease IV rates?"

"Can we use less radiographic contrast dye?" (To reduce hospital-acquired acute kidney injury, the nurse asks the health care team if less radiographic contrast dye can be given to reduce client exposure. Contrast dye is severely nephrotoxic, and other options can be used in its place.Air circulation and low-dose dopamine are not associated with nephrotoxicity. Prerenal status results from decreased blood flow to the kidney, such as fluid loss or dehydration. IV fluids can correct this decreased blood flow.)

A client is being treated for kidney failure. Which statement by the nurse encourages the client to express his or her feelings and concerns about the risk for death and the disruption of lifestyle? "All of this is new. What can't you do?" "Are you afraid of dying?" "How are you doing this morning?" "What concerns do you have about your kidney disease?"

"What concerns do you have about your kidney disease?" (Asking the client about any concerns regarding your disease is an open-ended statement and specific to the client's concerns.Asking the client to explain what he or she can't do implies inadequacy on the client's part. Asking the client if he or she is afraid of dying is too direct and would likely cause the client to be anxious. Asking the client how he or she is doing is too general and does not encourage the client to share thoughts on a specific topic.)

A client awaiting kidney transplantation states, "I can't stand this waiting for a kidney, I just want to give up." Which statement by the nurse is most therapeutic? "I'll talk to the health care provider and have your name removed from the waiting list." "You sound frustrated with the situation." "You're right, the wait is endless for some people." "I'm sure you'll get a phone call soon that a kidney is available."

"You sound frustrated with the situation." (The most therapeutic statement by the nurse is "You sound frustrated with the situation." This acknowledges the client's frustration and reflects the feelings the client is having by offering assistance and support.Talking to the health care provider and removing the client from the waiting list does not allow the nurse to hear more and perhaps offer therapeutic listening or a solution to the problem. Telling the client that the wait is endless for some people cuts the client off from sharing his or her concerns and accentuates the negative aspects of the situation. The waiting time for kidney matches is increasing due to a shortage of organs, so the nurse would not offer false hope by suggesting that the client will get a phone call soon.)

An injury that is caused by an external force contacting the head, placing the head in sudden motion, is known as what? Focal injury Diffuse injury Deceleration injury Acceleration injury

Acceleration injury (An acceleration injury is one in which an external force contacts the head and places the head in sudden motion. A deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object. A focal injury is confined to a specific area of the brain. A diffuse injury is when many areas of the brain are damaged.)

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? Achieving the highest level of functioning Increasing cerebral perfusion Preventing further injury Preventing skin breakdown

Achieving the highest level of functioning (The most important nurse's goal for the client with TBI is to help him or her achieve the highest level of functioning possible.The nurse assesses cerebral perfusion, such as oxygenation status, but cannot increase cerebral perfusion. Prevention of injury from falls, infection, or further impairment of cerebral perfusion is part of a larger goal for this client. Prevention of skin breakdown is a goal for the care of any client.)

When is the best time for the nurse to counsel the patient about the importance of dialysis therapy? During the first session of dialysis Before the start of the dialysis session After the initial reduction of uremic symptoms At the time when the patient is unmotivated and reluctant about dialysis

After the initial reduction of uremic symptoms (The initial reduction of uremic manifestations in the first few weeks after starting dialysis treatment creates a sense of physical, mental, and emotional well-being. Thus, this time is optimal for the nurse to counsel a patient about the positive effects of dialysis. Before or during the first session of dialysis, the patient may not understand the process. When a patient is unmotivated, he or she may not be able to listen to the positive outcomes of dialysis.)

Which chemical is directly associated with reduced urine volume in the renin-angiotensin-aldosterone pathway during an acute kidney injury? Renin Aldosterone Angiotensin I Angiotensin II

Aldosterone (Aldosterone acts on the kidney's tubules to increase the reabsorption of sodium and water into the blood; this chemical is directly associated with reduced urine output. When blood perfusion to the kidneys is reduced, the juxtaglomerular cells convert prorenin to renin. This converts angiotensinogen to angiotensin I. Angiotensin I is subsequently converted to angiotensin II in the lungs. Angiotensin II increases blood pressure and also stimulates the secretion of aldosterone.)

Which best describes hydrocephalus? A collection of blood An abnormal increase in cerebrospinal fluid The shifting and herniating of brain tissue downward The fluid accumulation between the cells of the brain

An abnormal increase in cerebrospinal fluid (Hydrocephalus is an abnormal increase in cerebrospinal fluid. If left untreated, this condition can lead to increased intracranial pressure. A collection of blood is a blood clot. The shifting and herniating of brain tissue downward describes brain herniation. The fluid accumulation between the cells of the brain describes interstitial edema.)

What is the best explanation of an open traumatic brain injury (TBI)? An injury in which the skull is fractured An injury in which the skull remains intact An injury that damages only the brain tissue An injury in which there is increased intracranial pressure (ICP)

An injury in which the skull is fractured (When the skull is fractured or pierced by a penetrating object, this is known as an open TBI. When only the brain tissue is damaged, this is a closed TBI. When the skull is still intact, this is a closed TBI. Increased ICP can cause closed, not open, TBIs.)

The nurse would question the use of mannitol (Osmitrol) for which patient condition? Increased intraocular pressure Anuria related to end-stage kidney disease Cerebral edema from head trauma Oliguria from acute renal failure

Anuria related to end-stage kidney disease (Mannitol does not influence urine production; it only increases existing urine output. It is not metabolized but excreted unchanged in the urine by the kidneys. Thus, if no urine is produced (anuria), mannitol is not excreted, which increases blood volume. Excess blood volume may cause the undesirable adverse effect of pulmonary edema.)

The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign/symptom is the nurse most concerned about? Amnesia Asymmetric pupils Headache Head laceration

Asymmetric pupils (The nurse is most concerned about asymmetric pupils in the client with traumatic brain injury. Asymmetric (uneven) pupils are treated as herniation of the brain from increased intracranial pressure (ICP) until proven otherwise. The nurse must report and document any changes in pupil size, shape, and reactivity to the primary health care provider immediately.Amnesia, a headache and a head laceration, can be signs of mild traumatic brain injuries and need to be investigated more thoroughly.)

When caring for a client with a left forearm arteriovenous fistula created for hemodialysis, which actions must the nurse take? Select all that apply. Check brachial pulses daily. Auscultate for a bruit every 8 hours. Teach the client to palpate for a thrill over the site. Elevate the arm above heart level. Ensure that no blood pressures are taken in that arm.

Auscultate for a bruit every 8 hours. Teach the client to palpate for a thrill over the site. Ensure that no blood pressures are taken in that arm. (A bruit or swishing sound and a thrill or buzzing sensation upon palpation would be present in this client, indicating patency of the fistula. No blood pressure, venipuncture, or compression, such as lying on the fistula, would occur.Distal pulses and capillary refill would be checked daily. For a forearm fistula, the radial pulse is checked instead of the brachial pulse which is proximal. Elevating the arm increases venous return, possibly collapsing the fistula.)

A client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? Auscultate for pericardial friction rub. Assess for crackles. Monitor for decreased peripheral pulses. Determine if the client is able to ambulate.

Auscultate for pericardial friction rub. (The additional assessment needed for the client with uremia is to auscultate the pericardium for friction rub. These clients are prone to pericarditis. Signs/symptoms of pericarditis include inspiratory chest pain, tachycardia, narrow pulse pressure, low-grade fever, and pericardial friction rub.Crackles and tachycardia are symptomatic of fluid overload. Fever is not present. Although the nurse will monitor pulses, and ambulation is important to prevent weakness and deep vein thrombosis, these are not pertinent to the constellation of signs/symptoms of pericarditis that the client presents with.)

Which instruction by the nurse will help a client with chronic kidney disease prevent renal osteodystrophy? Consuming a low-calcium diet Avoiding peas, nuts, and legumes Drinking cola beverages only once daily Increasing dairy products enriched with vitamin D

Avoiding peas, nuts, and legumes (To prevent renal osteodystrophy in a chronic kidney disease client the nurse needs to instruct the client to avoid peas, nuts, and legumes. Kidney failure causes hyperphosphatemia, so phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes must be restricted.Calcium would not be restricted. Hyperphosphatemia results in a decrease in serum calcium and demineralization of the bone. Cola beverages and dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.)

A client with a recently created vascular access for hemodialysis is being discharged. In planning discharge instructions, which information does the nurse include? Avoiding venipuncture and blood pressure measurements in the affected arm Modifications to allow for complete rest of the affected arm How to assess for a bruit in the affected arm How to practice proper nutrition

Avoiding venipuncture and blood pressure measurements in the affected arm (The nurse must teach the client to avoid venipunctures and blood pressure measures in the arm that contains the newly created vascular access device. Compression of vascular access causes decreased blood flow and may cause occlusion. If this occurs, lifesaving dialysis will not be possible.The arm with the access device must be exercised to encourage venous dilation, not rested. The client can palpate for a thrill, but a stethoscope is needed to auscultate the bruit at home. The nurse needs to take every opportunity to discuss nutrition, even as it relates to wound healing, but loss of the venous access device must take priority.)

Ch. 45: Care of Critically Ill Patients with Neurologic Problems

Ch. 45: Care of Critically Ill Patients with Neurologic Problems

Ch. 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease

Ch. 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease

A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for? Changes in breathing pattern Dizziness Increasing level of consciousness Reactive pupils

Changes in breathing pattern (The nurse monitors for changes in breathing pattern. This may be indicative of increased intracranial pressure secondary to compression of areas of the brain responsible for respiratory control. Dizziness is a symptom of brain injury, not increased intracranial pressure. Increasing level of consciousness and reactive pupils are desired outcomes for this client.)

The RN has just received change-of-shift report. Which of the assigned clients would be assessed first? Client with chronic kidney failure who was just admitted with shortness of breath Client with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted Client with azotemia whose blood urea nitrogen and creatinine are increasing Client receiving peritoneal dialysis who needs help changing the dialysate bag

Client with chronic kidney failure who was just admitted with shortness of breath (After the change-of-shift report, the nurse must first assess the newly admitted client with chronic kidney failure and shortness of breath, the dyspnea of the client with chronic kidney failure may indicate pulmonary edema and must be assessed immediately.The client with kidney insufficiency is stable and assessment can be performed later. The client with azotemia requires assessment and possible interventions but is not at immediate risk for life-threatening problems. The client receiving peritoneal dialysis can be seen last because it is a slow process and the client has no urgent needs.)

The nurse is caring for a patient who has been prescribed digoxin for acute kidney injury. What manifestations are likely to be observed in the patient experiencing digoxin toxicity? Select all that apply. Rapid weight gain High blood pressure Color vision changes Changes in mental ability Halos around bright lights

Color vision changes Changes in mental ability Halos around bright lights (Changes in color vision (for example, seeing more yellow color), halos around bright lights, and changes in mental ability are manifestations of digoxin toxicity. The drug must be stopped, or the dose must be temporarily reduced. High blood pressure and rapid weight gain are observed in patients taking synthetic erythropoietin, which can cause cardiovascular problems, such as myocardial infarction.)

To prevent prerenal acute kidney injury, which person is encouraged to increase fluid consumption? Construction worker Office secretary Schoolteacher Taxicab driver

Construction worker (Construction workers perform physical labor and work outdoors, especially in warm weather. Working in this type of atmosphere causes diaphoresis and places this worker at risk for dehydration and prerenal azotemia.The office secretary and schoolteacher work indoors and, even without air conditioning, will not lose as much fluid to diaphoresis as someone performing physical labor. The taxicab driver, even without air conditioning, will not experience diaphoresis and fluid loss like the construction worker.)

What are the early manifestations of pulmonary edema? Lethargy Thick white sputum Decreased heart rate Crackles at the base of the lungs

Crackles at the base of the lungs (Crackles heard on auscultation at the base of the lungs is an early manifestation of pulmonary edema. Fluid leakage from the pulmonary circulation into the lung tissue and alveoli cause increased heart rate; blood-tinged, frothy sputum; and restlessness.)

What statement is related to acute kidney injury (AKI)? AKI is progressive. AKI is associated with anemia. AKI causes permanent damage to the kidneys. Damage to 50 to 95% of nephrons results in an AKI.

Damage to 50 to 95% of nephrons results in an AKI. (AKI is a condition of reduced renal function. AKI is sudden in onset and is caused by damage to kidney tissue (damage of 50 to 95% of nephrons), resulting in hypotensive shock. The synthesis of erythropoietin is unaltered; therefore, AKI is not associated with anemia. AKI does not result in permanent damage to the kidneys.)

The nurse is monitoring a client after a craniotomy. Which sign/symptom does the nurse report immediately to the provider? Periorbital (eye socket) edema Bilateral ecchymoses (bruising) of both eyes Moderate amount of serosanguineous drainage on the head dressing Decorticate positioning

Decorticate positioning (In a postoperative craniotomy client, the nurse must immediately report decorticate positioning to the provider. The major complications of a craniotomy are increased intracranial pressure from cerebral edema or hydrocephalus and hemorrhage. Decorticate positioning indicates damage to the pathway between the brain and the spinal cord. Periorbital edema and a small-to-moderate amount of serosanguineous drainage are expected after a craniotomy. Ecchymoses in the facial region, especially around the eyes, are expected after a craniotomy.)

To evaluate the therapeutic effects of mannitol (Osmitrol), the nurse should monitor the patient for which clinical finding? Decrease in intracranial pressure Decrease in serum osmolality Increase in urine osmolality Increase in cerebral blood volume

Decrease in intracranial pressure (Mannitol is an osmotic diuretic that pulls fluid from extravascular spaces into the bloodstream to be excreted in urine. This decreases intracranial pressure and cerebral blood volume, increases excretion of medications, decreases urine osmolality, and increases serum osmolality.)

The nurse understands that which condition occurs in late chronic kidney disease? Hypokalemia Sodium depletion Decreased urine production Reduced phosphorus excretion

Decreased urine production (In the later stages of chronic kidney disease, urine production is decreased. Hyperkalemia, not hypokalemia, occurs. Sodium depletion and reduced phosphorus excretion are common in early chronic kidney disease.)

A client with end-stage kidney disease has been put on fluid restrictions. Which assessment finding indicates that the client has not adhered to this restriction? Blood pressure of 118/78 mm Hg Weight loss of 3 pounds (1.4 kg) during hospitalization Dyspnea and anxiety at rest Central venous pressure (CVP) of 6 mmHg

Dyspnea and anxiety at rest (The assessment finding that shows that the client has not adhered to fluid restriction is dyspnea and anxiety at rest. Dyspnea is a sign of fluid overload and possible pulmonary edema. The nurse needs to assist the client in correlating symptoms of fluid overload with nonadherence to fluid restriction.Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures. 118/78 mm Hg is a normal blood pressure. Excess fluid intake and fluid retention are manifested by an elevated CVP (>8 mm Hg) and weight gain, not weight loss.)

When assisting with dietary protein needs for a client on peritoneal dialysis, the nurse recommends that the client select which food? Eggs Ham Eggplant Macaroni

Eggs (The nurse recommends eggs as a dietary protein need for a client on peritoneal dialysis. Other suggested protein-containing foods for this client are milk and meat.Although a protein, ham is high in sodium and needs to be avoided. Vegetables and pasta contain mostly carbohydrates. Peritoneal dialysis clients are allowed 1.2 to 1.5 g of protein/kg/day because protein is lost with each exchange.)

What laboratory changes does the nurse expect in a patient with chronic kidney disease? Select all that apply. Elevated blood urea nitrogen (BUN) Elevated creatinine Elevated hemoglobin Increased serum calcium Decreased serum potassium

Elevated blood urea nitrogen (BUN) Elevated creatinine (In a patient with chronic kidney disease, the abnormal laboratory values the nurse would expect are elevated serum creatinine and elevated BUN. Serum calcium would be decreased, serum potassium would be increased, and hemoglobin levels would be decreased.)

Which clients are at risk for acute kidney injury (AKI)? Select all that apply. Football player in preseason practice Client who underwent contrast dye radiology Accident victim recovering from a severe hemorrhage Accountant with diabetes Client in the intensive care unit on high doses of antibiotics Client recovering from gastrointestinal influenza

Football player in preseason practice Client who underwent contrast dye radiology Accident victim recovering from a severe hemorrhage Client in the intensive care unit on high doses of antibiotics Client recovering from gastrointestinal influenza (To prevent AKI, all people must be urged to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity.Diabetes may cause acute kidney failure superimposed on chronic kidney failure.)

What does it mean if the patient has an indirect traumatic brain injury (TBI)? Force was applied directly to the patient's head. Force was applied to the head by an object or tool, not another body part. Force was applied to another body part, but the brain was still affected. Force was applied to the brain due to an accident and not an intentional injury.

Force was applied to another body part, but the brain was still affected. (TBIs can be direct or indirect. An indirect TBI means that force was applied to another part of the body, but the rebound effect went to the brain. An indirect injury does not imply the TBI was accidental, applied directly to the head, or caused by an object or tool.)

A patient with chronic kidney disease (CKD) has developed the Kussmaul pattern of respiration. What causes this breathing pattern? Increased pH Increased bicarbonate Increased acid retention Decreased rate and depth of breathing

Increased acid retention (As CKD progresses, more nephrons are lost and acid retention increases, leading to metabolic acidosis. This causes Kussmaul respiration. An increase in blood hydrogen levels leads to decreased pH. In CKD, ammonium production is decreased and reabsorption of bicarbonate does not occur. This leads to decreased levels of bicarbonate and buildup of hydrogen ions. The respiratory system compensates for the increased hydrogen ions by increasing the rate and depth of breathing, which helps excrete carbon dioxide through the lungs. This breathing pattern is known as Kussmaul respiration.)

Which clinical manifestation indicates the need for increased fluids in a client with kidney failure? Increased blood urea nitrogen (BUN) Increased creatinine level Pale-colored urine Decreased sodium level

Increased blood urea nitrogen (BUN) (An increase in BUN can be an indication of dehydration, and a needed increase in fluids.Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted and does not indicate that an increase in fluids is necessary. Sodium is increased, not decreased, with dehydration.)

What is the leading cause of death from head trauma in patients who reach the hospital alive? Hypoxia Hypotension Internal bleeding Increased intracranial pressure (ICP)

Increased intracranial pressure (ICP) (Increased ICP is the leading cause of death in patients who reach the hospital alive after having head trauma. Internal bleeding is a risk factor for death, but is not the leading cause. Hypoxia and hypotension commonly cause secondary injuries but are not the leading cause of death.)

An important component of the nursing assessment for patients at risk for acute kidney injury includes monitoring laboratory values. Which alteration does the nurse expect to find in a patient with kidney disease? Increased hematocrit Increased serum calcium Increased serum potassium Decreased serum magnesium

Increased serum potassium (Serum potassium is increased in a patient with kidney disease. Hematocrit is decreased to about 20 percent in patients with kidney disease. Serum calcium is decreased in a patient with kidney disease, and serum magnesium is increased.)

patient with chronic kidney disease wants to undergo peritoneal dialysis. What are the advantages of peritoneal dialysis? Select all that apply. It does not cause hyperlipidemia in patients. It requires a shorter time for treatment than hemodialysis. It is useful for patients who have had abdominal surgeries. It provides better blood pressure control than hemodialysis. It requires fewer dietary and fluid restrictions than hemodialysis.

It provides better blood pressure control than hemodialysis. It requires fewer dietary and fluid restrictions than hemodialysis. (Peritoneal dialysis provides better blood pressure control than hemodialysis because of hemodynamic tolerance. It requires fewer dietary and fluid restrictions than hemodialysis because it is a simpler process that is less stressful on the body. Peritoneal dialysis causes hyperlipidemia because of the excessive glucose load. It requires a longer time for treatment than hemodialysis because of the time-consuming exchanges of wastes, fluids, and electrolytes. Patients who have undergone abdominal surgeries cannot have peritoneal dialysis because the surface area of the peritoneal membrane is not sufficient for adequate dialysis exchange.)

Which assessment finding represents a positive response to erythropoietin (Epogen, Procrit) therapy? Hematocrit of 26.7% Potassium within normal range Absence of spontaneous fractures Less fatigue

Less fatigue (The assessment finding of less fatigue is considered a positive response to erythropoietin. Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue.A hematocrit value of 26.7% is low. Erythropoietin would restore the hematocrit to at least 36% to be effective. Erythropoietin stimulates the bone marrow to increase red blood cell production and maturation, increasing H&H, not potassium. Calcium supplements and phosphate binders prevent renal osteodystrophy and do not treat anemia.)

What is the most important variable to assess with any brain injury? Heart rate Blood pressure Body temperature Level of consciousness

Level of consciousness (Level of consciousness (LOC) is the most important variable to assess with any brain injury. Heart rate, blood pressure, and body temperature can be assessed after LOC is evaluated.)

Which instructions would the nurse give to a patient at discharge, following hospitalization for an acute kidney injury (AKI)? Select all that apply. Increase intake of foods rich in sodium. Increase intake of potassium-rich foods. Increase fluid consumption to flush waste. Limit the intake of foods containing phosphorus. Report a daily weight gain of 2 pounds or more.

Limit the intake of foods containing phosphorus. Report a daily weight gain of 2 pounds or more. (Until the kidney resumes baseline normal functioning, the patient should limit the intake of foods containing phosphorus because high blood phosphate levels cause hypocalcemia. The patient must also keep a daily weight measurement log and report a weight gain of 2 pounds or more over 24 hours to the health care provider. Weight gain may indicate the retention of fluids because of the deterioration of kidney function or a progression to chronic kidney disease. The patient must be taught to restrict, not increase, the consumption of dietary potassium and sodium, as low urine output can cause an increase in serum sodium and serum potassium levels. Fluid consumption is also restricted, not increased, in the patient to prevent fluid overload.)

Which medication is most effective in slowing the progression of kidney failure in a client with chronic kidney disease? Diltiazem (Cardizem) Lisinopril (Zestril) Clonidine (Catapres) Doxazosin (Cardura)

Lisinopril (Zestril) (Angiotensin-converting enzyme inhibitors such as Lisinopril (Zestril) are most effective in slowing the progression of kidney failure in a client with chronic kidney disease.Calcium channel blockers, such as diltiazem, may indirectly prevent kidney disease by controlling hypertension but are not specific to slowing progression of kidney disease. Vasodilators such as clonidine and doxazosin control blood pressure but do not specifically protect from kidney disease.)

The nurse is assessing a patient with chronic kidney disease and pericarditis. What manifestations of pericarditis does the nurse expect to find in the patient? Select all that apply. Halitosis Mild chest pain Low-grade fever Decreased pulse rate Pericardial friction rub

Low-grade fever Pericardial friction rub (The presence of low-grade fever is a manifestation of pericarditis, the inflammation of the pericardial sac by uremic toxins or infection. A pericardial friction rub is heard on auscultation over the left sternal border, indicating pericarditis or an inflammation of the pericardial sac. The patient experiences severe chest pain and an increased pulse rate. Halitosis, or bad breath, is caused by the breakdown of urea into ammonia. The reaction is catalyzed by the enzyme urease, present in the mouth. Halitosis is not a manifestation of pericarditis.)

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? Assessing for Grey Turner's sign Maintaining neutral head position Placing the client in the Trendelenburg position Suctioning the client frequently

Maintaining neutral head position (To prevent ICP in a client with traumatic brain injury who is being mechanically ventilated, the nurse needs to maintain the patent's head in a neutral position. Maintaining the head in neutral alignments prevents obstruction of blood flow and is an important component of ICP.Grey Turner's sign is a bluish gray discoloration in the flank region caused by retroperitoneal hemorrhage. The head of the bed needs to be at 30 degrees. The Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning would be avoided because it increases ICP.)

What intervention is appropriate for the patient with stage 4 chronic kidney disease (CKD)? Focusing on reduction of risk factors Implementing kidney transplantation Implementing strategies to slow CKD progression Managing complications and preparing for renal replacement

Managing complications and preparing for renal replacement (CKD is a progressive, irreversible disorder divided into five stages. Interventions for stage 4 CKD include managing complications and preparing for renal replacement therapy. Interventions for stage 3 CKD include implementing strategies to slow the disease progression. Interventions for stage 2 CKD include focusing on the reduction of risk factors such as diabetes mellitus. Interventions for stage 5 CKD include kidney transplantation.)

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? Dexamethasone (Decadron) Hydrochlorothiazide (HydroDIURIL) Mannitol (Osmitrol) Phenytoin (Dilantin)

Mannitol (Osmitrol) (In a postoperative craniotomy client with ICP, the nurse expects Mannitol to be requested to keep the ICP within a certain range. Mannitol is an osmotic diuretic used specifically to treat cerebral edema. Glucocorticoids have no demonstrated benefit in reducing ICP. Hydrochlorothiazide is only a mild diuretic and is not beneficial in maintaining ICP. Dilantin is used to treat seizure activity caused by increased ICP.)

The nurse is assessing the key features of severe chronic kidney disease in a patient. What term does the nurse use to document the presence of black and tarry stools? Melena Purpura Tachypnea Hyperpnea

Melena (Melena is the term used to document the presence of black and tarry stools. Tachypnea refers to the increase in the rate of breathing. Hyperpnea refers to an increase in the depth of breathing. Purpura refers to the presence of purple patches on the skin.)

The nurse teaches a client who is recovering from acute kidney disease to avoid which type of medication? Nonsteroidal anti-inflammatory drugs (NSAIDs) Angiotensin-converting enzyme (ACE) inhibitors Opiates Calcium channel blockers

Nonsteroidal anti-inflammatory drugs (NSAIDs) (Clients recovering from acute kidney disease need to be taught to avoid NSAIDs. NSAIDs may be nephrotoxic to a client with acute kidney disease and must be avoided.ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opiates may be used by clients with kidney disease if severe pain is present. Excretion, however, may be delayed. Calcium channel blockers can improve the glomerular filtration rate and blood flow within the kidney.)

The nurse teaches a patient who is recovering from acute kidney disease to avoid which medication? Opiates Calcium channel blockers Nonsteroidal anti-inflammatory drugs (NSAIDs) Angiotensin-converting enzyme (ACE) inhibitors

Nonsteroidal anti-inflammatory drugs (NSAIDs) (NSAIDs may be nephrotoxic to a patient with acute kidney disease and should be avoided. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic patient, from progression of kidney disease. Opiates may be used by patients with kidney disease if severe pain is present; however, excretion may be delayed. Calcium channel blockers can improve the glomerular filtration rate and blood flow within the kidney.)

While managing care for a client with chronic kidney disease, which actions does the registered nurse (RN) plan to delegate to unlicensed assistive personnel (UAP)? Select all that apply. Obtain the client's prehemodialysis weight. Check the arteriovenous (AV) fistula for a thrill and bruit. Document the amount the client drinks throughout the shift. Auscultate the client's lung sounds every 4 hours. Explain the components of a low-sodium diet.

Obtain the client's prehemodialysis weight. Document the amount the client drinks throughout the shift. (Actions the RN delegates to the UAP include: obtaining the client's weight and documenting oral fluid intake. These are routine tasks that can be performed by a UAP.Assessment skills (checking the AV fistula and auscultating lung sounds) and client education (explaining special diet) require more education and are in the legal scope of practice of the RN.)

Which describes secondary brain injuries? Result in contusion Caused by indirect forces Occur after the initial injury Cause additional injuries in the body

Occur after the initial injury (Secondary brain injuries are injuries that occur after the initial injury and worsen the patient's outcome. They do not always result in contusion. Secondary injuries do not cause additional injuries, though they can negatively affect other physiological processes. Secondary brain injuries are not necessarily caused by indirect forces.)

The nurse plans pharmacologic management for a patient with pain. The nurse should administer the pain medication based on what dosage schedule? Pain relief is best obtained by administering analgesics around the clock. Administer the analgesic when the pain level reaches a "6" on a scale of 1 to 10. Opioid analgesics should not be used for more than 24 hours to prevent drug addiction. Analgesics should be administered as needed (prn) to minimize adverse effects.

Pain relief is best obtained by administering analgesics around the clock. (When pain is present for more than 12 hours a day, analgesic dosages are best administered around the clock rather than on an as-needed basis, but dosages should always be within the dosage guidelines for each drug used. The around-the-clock (or "scheduled") dosing maintains steady-state levels of the medication and prevents drug troughs and escalation of pain.)

A patient has chronic kidney disease and pericarditis. What manifestations of pericarditis does the nurse find on assessment? High fever Mild chest pain Decreased pulse rate Pericardial friction rub

Pericardial friction rub (Pericardial friction rub is heard on auscultation over the left sternal border in the patient with pericarditis. This follows inflammation of the pericardial sac by uremic toxins or infection. The patient with pericarditis experiences severe chest pain, low-grade fever, and increased pulse rate. When pericardial effusion worsens, dysrhythmias may develop, blood pressure decreases, and the patient may have shortness of breath.)

A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client? Calling the Stroke Team Establishing an IV Positioning the client to prevent aspiration Preparing for thrombolytic administration

Positioning the client to prevent aspiration (Positioning the client while maintaining cervical spine immobilization to prevent aspiration is the nurse's priority intervention. Maintaining a patent airway is essential especially since this client is vomiting.Calling the Stroke Team would not be necessary. Establishing an IV is important for this client but it is not the first priority. If this client was having a stroke, thrombolytics would be contraindicated because of the fall with head strike.)

An intubated, mechanically ventilated patient in the intensive care unit (ICU) is becoming increasingly restless and anxious. The nurse expects to administer which intravenous (IV) anesthetic drug? Propofol Fentanyl Morphine sulfate Naloxone

Propofol (Propofol is an IV sedative-hypnotic drug used for induction and maintenance of anesthesia as well as for sedation in patients who are intubated and mechanically ventilated in the ICU. It has a rapid onset and short duration of action, allowing for easy titration and maintenance of the patient's level of consciousness.)

A nurse is listening to family members discuss feelings of guilt and anger over a patient's traumatic brain injury. How does the nurse document this type of assessment? Imaging Physical Laboratory Psychosocial

Psychosocial (Discussing family members' feelings and coping strategies is a part of a psychosocial assessment. Examining the patient's appearance and reflexes are examples of parts of the physical assessment. Blood tests encompass the laboratory assessment. Imaging techniques like computed tomography and magnetic resistance imaging scans comprise the imaging assessment.)

When assessing for the MOST serious adverse effect to an opioid analgesic, what does the nurse monitor for in this patient? Blood pressure Respiratory rate Mental status Heart rate

Respiratory rate (The most serious adverse effect of opioid analgesics is respiratory depression.)

The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? Select all that apply. Restricted protein Liberal sodium Restricted fluids Low potassium Low fat

Restricted protein Restricted fluids Low potassium (A client with acute kidney injury needs to modify the diet to include restricted protein, restricted fluids, and low potassium. Breakdown of protein leads to azotemia and increased blood urea nitrogen. For the client who does not require dialysis, 0.6 g/kg of body weight or 40 g/day of protein is usually prescribed. For clients who do require dialysis, the protein level needed will range from 1 to 1.5 g/kg. Fluid is restricted during the oliguric stage. The daily amount of fluid permitted is calculated to be equal to the urine volume plus 500 mL. Potassium intoxication may occur, so dietary potassium is also restricted. Dietary potassium is restricted to 60 to 70 mEq/kg (70 mmol/kg).Sodium is restricted during AKI because oliguria causes fluid retention. Dietary sodium recommendations range from 60 to 90 mEq/kg (60 to 90 mmol/kg). Fats may be used for needed calories when proteins are restricted.)

The nurse knows that a patient's glomerular filtration rate of 22 mL/min signifies that the patient is in which stage of chronic renal disease? Stage 2, mild chronic kidney disease Stage 3, moderate chronic kidney disease Stage 4, severe chronic kidney disease Stage 5, end-stage kidney disease

Stage 4, severe chronic kidney disease (Stage 4, severe chronic kidney disease, is characterized by a glomerular filtration rate of 15 to 29 mL/min. Stage 2, mild chronic kidney disease, is characterized by a glomerular filtration rate of 60 to 89 mL/min. Stage 3, moderate chronic kidney disease is characterized by a glomerular filtration rate of 30 to 59 mL/min. Stage 5, end-stage kidney disease, is characterized by a glomerular filtration rate of less than 15 mL/min.)

The nurse provides care for a patient admitted with an acute kidney injury. Which characteristics of the condition does the nurse expect this patient to exhibit? Select all that apply. Sudden onset Gradual onset May not progress Quickly progressing Nephron involvement between 50 and 95 percent

Sudden onset May not progress Nephron involvement between 50 and 95 percent (Characteristics of acute kidney injury include sudden onset, kidney damage that may not progress, and 50 to 95 percent nephron involvement. Acute kidney injury does not have a gradual onset and does not progress quickly.)

When caring for a client with acute kidney injury and a temporary subclavian hemodialysis catheter, which assessment finding does the nurse report to the provider (HCP)? Mild discomfort at the insertion site Temperature 100.8°F (38.2°C) 1+ ankle edema Anorexia

Temperature 100.8°F (38.2°C) (In this client situation, the nurse reports an assessment finding of a temperature of 100.8°F (38.2°C) to the HCP. Infection is a major complication of temporary catheters. All symptoms of infection, including fever, must be reported to the provider because the catheter may have to be removed.Mild discomfort at the insertion site is expected with a subclavian hemodialysis catheter. During acute injury, oliguria with resulting fluid retention and 1+ ankle edema is expected. Rising blood urea nitrogen may result in anorexia, nausea, and vomiting.)

When caring for a client who receives peritoneal dialysis (PD), which finding does the nurse report to the provider (HCP) immediately? Pulse oximetry reading of 95% Sinus bradycardia, rate of 58 beats/min Blood pressure of 148/90 mm Hg Temperature of 101.2°F (38.4°C)

Temperature of 101.2°F (38.4°C) (The nurse needs to immediately report a peritoneal dialysis client's temperature of 101.2°F (38.4°C) to the HCP. Peritonitis is the major complication of PD, caused by intra-abdominal catheter site contamination. Meticulous aseptic technique must be used when caring for PD equipment.A pulse oximetry reading of 95% is a normal saturation. Although a heart rate of 58 beats/min is slightly bradycardic, the HCP can be informed upon visiting the client. Clients with kidney failure tend to have slightly higher blood pressures due to fluid retention. This is not as serious as a fever.)

If a patient has a traumatic brain injury (TBI) with ataxia, what does that mean? The patient has hypotension. The patient has a blood clot. The patient cannot see colors. The patient has a loss of balance.

The patient has a loss of balance. (Ataxia means loss of balance. Ataxia does not mean that the patient has hypotension, a blood clot, or an inability to see colors.)

The nurse reads the patient's health record and sees that the patient's brain is contused. What does the nurse infer from this? The patient's brain is torn. The patient's brain is bruised. The patient has a shearing injury. The patient had a direct injury.

The patient's brain is bruised. (Contused is another word for bruised. If the patient had a shearing injury, the health record would indicate nerve axonal injury. If the patient's brain were torn, the health record would indicate a laceration. A direct injury does not describe a contusion.)

How do nonsteroidal anti-inflammatory drugs (NSAIDs) cause acute kidney injury? Through renal damage Through renal obstruction Through renal hypoperfusion Through renal hematoma formation

Through renal hypoperfusion (NSAIDs inhibit the secretion of prostaglandins, which are essential for the vasodilatation of the afferent arterioles of the glomeruli and the maintenance of the glomerular filtration rate (GFR). NSAIDs drastically reduce the GFR and cause renal hypoperfusion. The use of NSAIDs does not directly cause any damage to the anatomic structures of the kidney; thus, there is no associated renal damage, hematoma formation, or renal obstruction.)

What is the role of alarms in renal replacement (dialysis) therapy? To detect hypotension To detect hypovolemia To detect hypoperfusion To detect an air embolus

To detect an air embolus (The pump used in continuous venous hemofiltration during dialysis may increase the risk of an air embolus. Alarms are set and monitored by the dialysis technician or nurse to ensure the safe and effective flow of air. Hypotension is detected by monitoring central venous pressure; this condition is caused by hypovolemia and hypoperfusion. Hypovolemia is detected by blood osmolarity levels. Hypoperfusion is detected by monitoring serum creatinine levels.)

The urinalysis report of a patient suffering from acute kidney injury (AKI) reveals the presence of red blood cell casts and hemoglobin. What etiology of AKI should the nurse anticipate? Myocardial infarction Atherosclerosis Hypovolemic shock Tubular damage in kidneys

Tubular damage in kidneys (Inflammation, infection, and nephrotoxic drugs may result in irreparable nephron injury and tubular damage in the kidneys. This category of AKI is termed intrarenal because the damage is to the nephron and tubule itself. Intrarenal AKI is characterized by the presence of sediments of red blood cells, myoglobin, hemoglobin, and tubular debris in the urine. Myocardial infarction, atherosclerosis, and hypovolemic shock can result in AKI as a result of renal hypoperfusion. This category of AKI is termed prerenal, meaning that the problem causing the dysfunction happens "before" or "in front of" the kidney. No renal nephron or tubule pathology is involved in these conditions, so there will not be the urinalysis findings that are indicated in the scenario presented.)

While assisting a client during peritoneal dialysis, the nurse observes the drainage stop after 200 mL of peritoneal effluent drains into the bag. What action should the nurse implement first? Instruct the client to deep-breathe and cough. Document the effluent as output. Turn the client to the opposite side. Reposition the catheter.

Turn the client to the opposite side. (The nurse's first action in this situation is to turn the client to the opposite side. With peritoneal dialysis, usually 1 to 2 L of dialysate is infused by gravity into the peritoneal space. The fluid dwells in the peritoneal cavity for a specified time, then drains by gravity into a drainage bag. The peritoneal effluent or outflow generally is a continuous stream after the clamp is completely open. Potential causes of flow difficulty include constipation, kinked or clamped connection tubing, the client's position, fibrin clot formation, and catheter displacement. If inflow or outflow drainage is inadequate, reposition the client to stimulate inflow or outflow. Turning the client to the other side or ensuring that he or she is in good body alignment may help.Instructing the client to deep-breathe and cough will not promote dialysate drainage. Increased abdominal pressure from coughing contributes to leakage at the catheter site. The nurse needs to measure and record the total amount of outflow after each exchange. However, the nurse needs to reposition the client first to assist with complete dialysate drainage. An x-ray is needed to identify peritoneal dialysis catheter placement. Only the physician repositions a displaced catheter.)

What is the amount of fluid to be taken for a patient recovering from acute kidney injury? Urine output with an additional 300 mL Urine output with an additional 500 mL Urine output with an additional 700 mL Urine output with an additional 1000 mL

Urine output with an additional 500 mL (The patients with renal failure should be very carefully monitored regarding the fluid intake. The daily intake should be 500 mL in addition to the urine volume. Lower than 500 mL may lead to dehydration of the body; higher than 500 mL may lead to fluid excess and excess pressure upon the healing kidneys.)

A patient with a traumatic brain injury underwent monitoring of the intracranial pressure. Suddenly, it resulted in leakage of the cerebrospinal fluid. What would be the possible reason for the leakage? Use of intraventricular catheter Use of subarachnoid bolt or screw Use of subdural/epidural catheter or sensor Use of fiberoptic transducer-tipped catheter

Use of intraventricular catheter (When an intraventricular catheter is used, a hole is created in the skull by drilling, and the catheters are inserted through the brain to an area where the cerebrospinal fluid is present. It is the most invasive device, and cerebrospinal fluid leakage may occur near the insertion site. Use of subarachnoid bolt or screw, subdural/epidural catheter or sensor, and fiberoptic transducer-tipped catheter may not cause cerebrospinal fluid leakage. This is because the catheters are not placed in the region of the cerebrospinal fluid.)

Which factor represents a sign or symptom of digoxin toxicity? Serum digoxin level of 1.2 ng/mL (1.5 nmol/L) Polyphagia Visual changes Serum potassium of 5.0 mEq/L (5.0 mmol/L)

Visual changes (A sign/symptom of digoxin toxicity is represented by visual changes. Other signs/symptoms include anorexia, nausea, vomiting, restlessness, headache, fatigue, confusion, bradycardia, and tachycardia.A digoxin level of 1.2 mg/mL (1.5 nmol/L) is normal (0.8 to 2.0 mg/mL [1.02 to 2.56 nmol/L]). Polyphagia is a symptom of diabetes. Although hypokalemia may predispose to digoxin toxicity, this represents a normal, not low, potassium value.)

During which time frame does an acute subdural hematoma (SDH) present? Within 48 hours after impact Within one week after impact Within two weeks after impact Within two months after impact

Within 48 hours after impact (Acute SDHs present within 48 hours after impact. A subacute SDH will present within 48 hours to two weeks after impact. A chronic SDH will present from two weeks to several months after impact.)

A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this client's history? a. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" b. "Do you have anyone in your family with renal failure?" c. "Have you had a diet that is low in protein recently?" d. "Has a relative had a kidney transplant lately?"

a. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" (There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the client since both the serum creatinine and BUN are elevated, indicating some renal problems. A family history of renal failure and kidney transplantation would not be part of the questioning and could cause anxiety in the client. A diet high in protein could be a factor in an increased BUN.)

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed? a. "I am thrilled that I can continue to eat fast food." b. "I will cut out bacon with my eggs every morning." c. "My cooking style will change by not adding salt." d. "I will probably lose weight by cutting out potato chips."

a. "I am thrilled that I can continue to eat fast food." (Fast food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.)

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. "I know I can take care of all these needs by myself." b. "I need to seek counseling because I am very angry." c. "Hopefully things will improve gradually over time." d. "With respite care and support, I think I can do this."

a. "I know I can take care of all these needs by myself." (This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word "hopefully." Realizing the importance of respite care and support also is a realistic outlook.)

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.) a. "You will not need vascular access to perform PD." b. "There is less restriction of protein and fluids." c. "You will have no risk for infection with PD." d. "You have flexible scheduling for the exchanges." e. "It takes less time than hemodialysis treatments."

a. "You will not need vascular access to perform PD." b. "There is less restriction of protein and fluids." d. "You have flexible scheduling for the exchanges." (PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.)

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings.

a. A client with a moderate trauma may need hospitalization. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings. ("Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.)

A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the health care provider for orders.

a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. d. Administer a 250-mL bolus of normal saline. (Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the health care provider contacted.)

A 70-kg adult with chronic renal failure is on a low protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern? a. Albumin level of 2.5 g/dL b. Phosphorus level of 5 mg/dL c. Sodium level of 135 mmol/L d. Potassium level of 5.5 mmol/L

a. Albumin level of 2.5 g/dL (Protein restriction is necessary with chronic renal failure due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level (normal range 3.4-5.4) since this indicates that the protein in the diet is not enough for the client's metabolic needs. The electrolyte values are not related to the protein-restricted diet.)

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best? a. Ask the client how long ago the clip was placed. b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip. d. Reschedule the client for computed tomography.

a. Ask the client how long ago the clip was placed. (Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives.)

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.

a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. (All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.)

A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.

a. Assess whether or not the client can write. (Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up "words" often used by clients with sensory aphasia.)

A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse? a. Blood pressure of 76/58 mm Hg b. Sodium level of 138 mEq/L c. Potassium level of 5.5 mEq/L d. Pulse rate of 90 beats/min

a. Blood pressure of 76/58 mm Hg (Hypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The specially trained nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 90 beats/min is normal.)

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.

a. Call the provider or Rapid Response Team. (These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.)

A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best? a. Check the client's digoxin (Lanoxin) level. b. Administer an anti-nausea medication. c. Ask if the client is able to eat crackers. d. Get a referral to a gastrointestinal provider.

a. Check the client's digoxin (Lanoxin) level. (These signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication. Administering antiemetics, asking if the client can eat, and obtaining a referral to a specialist all address the client's symptoms but do not lead to the cause of the symptoms.)

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 (A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.)

A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise

a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence (After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.)

A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to him. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis.

a. Discuss what the treatment regimen means to him. (The initial action for the nurse is to assess anxiety, coping styles, and the client's acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the client's acceptance of the treatment should come first.)

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope.

a. Explain that personality changes are common following brain injuries. (Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn't useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouse's concerns and feelings.)

A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the client to drink 2 to 3 liters of water daily. d. Perform an electrocardiogram.

a. Give the client a bottle of water immediately. (This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the client to drink 2 to 3 liters of water each day. An intravenous line may be ordered later, after the client's degree of dehydration is assessed. An electrocardiogram is not necessary at this time.)

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client's spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories

a. Lower sodium c. Lower potassium e. Higher calories (Many clients with AKI are too ill to meet caloric goals and require tube feedings with kidney-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.)

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis (kidney stones) d. Firefighter with severe burns e. Young woman with lupus

a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis (Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and ureterolithiasis, causes post-renal AKI. Severe burns would be a pre-renal cause. Lupus would be an intrarenal cause for AKI.)

A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best? a. Obtain daily weights of the client. b. Auscultate heart and breath sounds. c. Palpate the client's abdomen. d. Assess the client's diet history.

a. Obtain daily weights of the client. (Furosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds should be assessed if there is fluid retention, as in heart failure. Palpation of the client's abdomen is not necessary, but the nurse should check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effect of the medication.)

A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the client's intake and output. d. Ask to have the laboratory redraw the blood specimen.

a. Place the client on a cardiac monitor immediately. (The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.)

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg

a. Urine output of 100 mL in 4 hours c. Large amount of sediment in the urine e. Blood pressure of 90/60 mm Hg (The low urine output, sediment, and blood pressure should be reported to the provider. Postoperatively, the nurse should measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hour for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours should be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal.)

The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse? a. "My sodium level changes by movement from the blood into the dialysate." b. "Dialysis works by movement of wastes from lower to higher concentration." c. "Extra fluid can be pulled from the blood by osmosis." d. "The dialysate is similar to blood but without any toxins."

b. "Dialysis works by movement of wastes from lower to higher concentration." (Dialysis works using the passive transfer of toxins by diffusion. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. The other statements show a correct understanding about hemodialysis.)

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "I can continue to take antacids to relieve heartburn." b. "I need to ask for an antibiotic when scheduling a dental appointment." c. "I'll need to check my blood sugar often to prevent hypoglycemia." d. "The dose of my pain medication may have to be adjusted." e. "I should watch for bleeding when taking my anticoagulants."

b. "I need to ask for an antibiotic when scheduling a dental appointment." c. "I'll need to check my blood sugar often to prevent hypoglycemia." d. "The dose of my pain medication may have to be adjusted." e. "I should watch for bleeding when taking my anticoagulants." (In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).)

The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.) a. "I need to decrease sodium, cholesterol, and protein in my diet." b. "My weight should be maintained at a body mass index of 30." c. "Smoking should be stopped as soon as I possibly can." d. "I can continue to take an aspirin every 4 to 8 hours for my pain." e. "I really only need to drink a couple of glasses of water each day."

b. "My weight should be maintained at a body mass index of 30." d. "I can continue to take an aspirin every 4 to 8 hours for my pain." e. "I really only need to drink a couple of glasses of water each day." (Weight should be maintained at a body mass index (BMI) of 22 to 25. A BMI of 30 indicates obesity. The use of nonsteroidal anti-inflammatory drugs such as aspirin should be limited to the lowest time at the lowest dose due to interference with kidney blood flow. The client should drink at least 2 liters of water daily. Diet adjustments should be made by restricting sodium, cholesterol, and protein. Smoking causes constriction of blood vessels and decreases kidney perfusion, so the client should stop smoking.)

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the client's magnesium level. b. Assess the client's sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

b. Assess the client's sodium level. (This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the client's serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.)

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95° F (35° C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mmHg since admission

b. Client in a coma for 2 weeks from a motor vehicle crash (In order to determine brain death, clients must meet four criteria: 1: coma from a known cause 2: normal or near-normal core temperature 3: normal systolic blood pressure 4: at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.)

The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding? a. Woman with a blood pressure of 158/90 mm Hg b. Client with Kussmaul respirations c. Man with skin itching from head to toe d. Client with halitosis and stomatitis

b. Client with Kussmaul respirations (Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. Hypertension is common in most clients with CKD, and skin itching increases with calcium-phosphate imbalances, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.)

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client's care? a. Edema and pain b. Electrolyte and fluid imbalance c. Cardiac and respiratory status d. Mental health status

b. Electrolyte and fluid imbalance (This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client's cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.)

A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics. b. Ensure that informed consent is on the chart. c. Perform a full neurologic assessment. d. Review the client's medication lists.

b. Ensure that informed consent is on the chart. (For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.)

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home

b. Is allergic to acetaminophen (Tylenol) d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home (Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.)

The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client's recent history? a. Pyelonephritis b. Myocardial infarction c. Bladder cancer d. Kidney stones

b. Myocardial infarction (Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI related to urine flow obstruction.)

A patient in the neurologic intensive care unit is being treated for cerebral edema. Which class of diuretic is used to reduce intracranial pressure? a. Loop diuretics b. Osmotic diuretics c. Thiazide diuretics d. Vasodilators

b. Osmotic diuretics (Mannitol, an osmotic diuretic, is commonly used to reduce intracranial pressure and cerebral edema resulting from head trauma.)

A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device.

b. Perform hand hygiene before client care. (All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.)

A client's mean arterial pressure is 60 mmHg and intracranial pressure is 20 mmHg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information

b. Poor prognosis and cognitive function (The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 - 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.)

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. Take a sample of the effluent and send to the laboratory. (An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.)

The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? a. "I should leave the drainage bag above the level of my abdomen." b. "I could flush the tubing with normal saline if the flow stops." c. "I should take a stool softener every morning to avoid constipation." d. "My diet should have low fiber in it to prevent any irritation."

c. "I should take a stool softener every morning to avoid constipation." (Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.)

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm

c. Administering intravenous fluids through the AV fistula (The nurse should not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula should be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.)

A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion

c. Maintaining a balanced intake and output (With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.)

The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8° F (37.6° C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the client's temperature. d. Connect the client to an electrocardiographic (ECG) monitor.

c. Monitor the client's temperature. (During hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The client's temperature could reflect the temperature of the dialysate. There is no indication to check the white blood cell count or connect the client to an ECG monitor. The other vital signs are within normal limits.)

The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care

c. Needs frequent re-orientation (This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care.)

A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs

c. No adventitious sounds in the lungs (The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the client's body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.)

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the client's vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.

c. Notify the Rapid Response Team. (This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.)

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown

c. Risk for acquiring an infection (The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.)

A client with chronic kidney disease states, "I feel chained to the hemodialysis machine." What is the nurse's best response to the client's statement? a. "That feeling will gradually go away as you get used to the treatment." b. "You probably need to see a psychiatrist to see if you are depressed." c. "Do you need help from social services to discuss financial aid?" d. "Tell me more about your feelings regarding hemodialysis treatment."

d. "Tell me more about your feelings regarding hemodialysis treatment." (The nurse needs to explore the client's feelings in order to help the client cope and enter a phase of acceptance or resignation. It is common for clients to be discouraged because of the dependency of the treatment, especially during the first year. Referrals to a mental health provider or social services are possibilities, but only after exploring the client's feelings first. Telling the client his or her feelings will go away is dismissive of the client's concerns.)

A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)? a. Antibiotic b. Histamine blocker c. Bronchodilator d. Angiotensin-converting enzyme (ACE) inhibitor

d. Angiotensin-converting enzyme (ACE) inhibitor (ACE inhibitors stop the conversion of angiotensin I to the vasoconstrictor angiotensin II. This category of medication also blocks bradykinin and prostaglandin, increases renin, and decreases aldosterone, which promotes vasodilation and perfusion to the kidney. Antibiotics fight infection, histamine blockers decrease inflammation, and bronchodilators increase the size of the bronchi; none of these medications helps slow the progression of CKD in clients with hypertension.)

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mmHg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO₂ of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C)

d. Client who has a temperature of 102° F (38.9° C) (A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO₂ of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.)

A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best? a. Administer cefazolin since the level of the antibiotic must be maintained. b. Hold the vitamins but administer the cefazolin. c. Hold the cefazolin but administer the vitamins. d. Hold all medications since both cefazolin and vitamins are dialyzable.

d. Hold all medications since both cefazolin and vitamins are dialyzable. (Both the cefazolin and the vitamins should be held until after the hemodialysis is completed because they would otherwise be removed by the dialysis process.)

A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? a. Use the catheter for the next laboratory blood draw. b. Monitor the central venous pressure through this line. c. Access the line for the next intravenous medication. d. Place a heparin or heparin/saline dwell after hemodialysis.

d. Place a heparin or heparin/saline dwell after hemodialysis. (The central line should have a heparin or heparin/saline dwell after hemodialysis treatment. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids.)

A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the client's nose and around the intravenous catheter. What action by the nurse is the priority? a. Hold pressure over the client's nose for 10 minutes. b. Take the client's pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.

d. Prepare protamine sulfate for administration. (Heparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the client's system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.)

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse's priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the client's pulse. d. Slow down the normal saline infusion.

d. Slow down the normal saline infusion. (The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the client's hemodynamic status, but this should not be the initial action by the nurse. Vital signs are also important after adjusting the intravenous infusion.)