Crisis 2 - Exam 3
The nurse is admitting a patient diagnosed with Gullain-Barre syndrome (GBS). Which question should the nurse ask the patient?
"Have you had a viral illness in the last few weeks?"
The nurse is reinforcing teaching with a patient newly diagnosed with ALS. Which statement would be appropriate to include in the teaching?
"This is a progressive disease that eventually results in permanent paralysis, though you will not lose any cognitive function."
A nurse is teaching a patient who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching?
"This medication may cause your skin to appear yellow in color."
The patient diagnosed with MS is crying and tells the nurse, "Why me? I did not do anything to deserve this!" Which is the nurses most therapeutic response?
"This must be difficult for you. Would you like to talk about your feelings?"
The client diagnosed with septic meningitis is admitted to the medical floor at noon. Which health-care provider's order would have the highest priority? 1. Administer an intravenous antibiotic. 2. Obtain the client's lunch tray. 3. Provide a quiet, clam, and dark room. 4. Weigh the client in hospital attire.
1. Administer an intravenous antibiotic.
The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client's problem as "high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Perform active range-of-motion exercises every four hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them
1. Position the client with the head of the bed elevated at intervals.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke. Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic 2. The client has weakness on the right side of the body 3. The client has complete bilateral paralysis of the arms and legs 4. The client has weakness on the right side of the face and tongue 5. The client has lost the ability to move the right arm but is able to walk independently 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance
1. The client is aphasic 2. The client has weakness on the right side of the body 4. The client has weakness on the right side of the face and tongue
Which is the expected outcome for a client diagnosed with encephalitis? 1. The client will regain as much neurological function as possible. 2. The client will have no short-term memory loss. 3. The client will have improved renal function. 4. The client will apply hydrocortisone cream daily.
1. The client will regain as much neurological function as possible.
The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with Steri-Strips. Which signs/symptoms would warrant transferring the resident to the emergency department? 1. A 4 cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.
2. A weak pulse, shallow respirations, and cool pale skin.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two hours. 5. Administer mild sedatives.
2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 5. Administer mild sedatives.
The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.
2. An intravenous osmotic diuretic.
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer and antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2 x 2 gauze under the nose to collect drainage.
3. Test the drainage for presence of glucose.
The nurse has instructed the family of a client with stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."
4. "We need to remind him to turn his head to scan the lost visual field."
A 31 year old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse had priority? 1. Assess lung sounds 2. Assess the six cardinal fields of gaze 3. Assess apical pulse 4. Assess level of consciousness
4. Assess level of consciousness
The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self
4. Consistently uses adaptive equipment in dressing self
The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate intravenous access. 4. Maintain an adequate airway.
4. Maintain an adequate airway
A nurse in a clinic is teaching a patient who has ulcerative colitis. Which of the following statements by the patient indicates understanding of the teaching? A. "I plan to limit fiber in my diet." B. 'I will restrict fluid intake during meals." C. "I will switch to black tea instead of drinking coffee." D. "I will try to eat three moderate to large meals a day*
A. "I plan to limit fiber in my diet."
The nurse is providing discharge teaching for a patient with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the patient indicates a need for further instruction? A. "I should increase the fiber in my diet." B. "I will need to avoid caffeinated beverages." C. "I'm going to learn some stress reduction techniques." D. "I can have exacerbations and remissions with Crohn's disease."
A. "I should increase the fiber in my diet."
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent acute renal failure (ARF)? A. Administer normal saline IV B. Take vital signs C. Place client on telemetry D. Assess abdominal dressing
A. Administer normal saline IV Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys. Significant blood loss is expected in the client with a gunshot wound.
A nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply) A. Assess for jugular vein distention B. Provide frequent mouth rinses C. Auscultate for a pleural friction rub D. Provide a high-sodium diet E.Monitor for dysrhythmias
A. Assess for jugular vein distention B. Provide frequent mouth rinses C. Auscultate for a pleural friction rub E.Monitor for dysrhythmias
A nurse is completing discharge teaching with a patient who has irritable bowel syndrome (18S). Which of the following instructions should the nurse include in the teaching? A. Avoid foods that trigger exacerbation. B. Consume 15 to 20 grams of fiber daily. C. Plan three moderate to large meals per day. D. Drink fluids at meal time,
A. Avoid foods that trigger exacerbation.
The nurse is planning post procedure care for a client who received hemodialysis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply)
A. Check BUN and serum creatinine B. Administer medications the nurse withheld prior to dialysis C. Observe for signs of hypovolemia D. Assess the access site for bleeding E. Evaluate blood pressure on the arm with AV access
A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication? A. Hematocrit of 33% B. Platelet count of 400,000 C. White blood cells 6,000 D. Blood urea nitrogen level of 15
A. Hematocrit of 33% Epoetin alfa is a synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to treat anemia associated with chronic kidney disease. The normal hematocrit level is 42-52% male, 37-47% female. Therapeutic effect is seen when the hematocrit reaches between 30-33%.
Which criteria must be met for a diagnosis of metabolic syndrome? (Select all that apply) A. Hypertension B. Elevated triglycerides C. Elevated serum glucose level D. Increased waist circumference E. Decreased low-density lipoproteins (LDL)
A. Hypertension B. Elevated triglycerides C. Elevated serum glucose level D. Increased waist circumference
A patient has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? A. Malaise B. Dark stools C. Weight gain D. LUQ discomfort
A. Malaise
A nurse is planning care for a client who will undergo peritoneal dialysis. Which of the following actions should the nurse take? (select all that apply) A. Monitor serum glucose levels B. Report cloudy dialysate return C. Warm the dialysate in a microwave oven D. Assess for shortness of breath (sob) E. Maintain medical asepsis when accessing the catheter insertion site
A. Monitor serum glucose levels B. Report cloudy dialysate return D. Assess for shortness of breath (sob) E. Maintain medical asepsis when accessing the catheter insertion site
A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury. Which of the following actions should the nurse take? (select all that apply) A. Review the medications the client currently takes B. Assess the AV fistula for a bruit C. Calculate the client's hourly urine output D. Measure the client's weight E. Check serum electrolytes F. Use the access site area for venipuncture
A. Review the medications the client currently takes B. Assess the AV fistula for a bruit D. Measure the client's weight E. Check serum electrolytes A - By reviewing the medications the client currently takes, the nurse can determine which medications to withhold until after dialysis B - Assessing the AV fistula for a bruit determines the patency of the fistula for dialysis D - Measuring the client's weight before dialysis is essential for comparing it with the client's weight after dialysis E - Checking the serum electrolytes determines the need for dialysis
The nurse is monitoring a patient for the early sign and symptoms of dumping syndrome. Which findings indicate this occurrence? A. Sweating and pallor B. Bradycardia and indigestion C. Double vision and chest pain D. Abdominal cramping and pain
A. Sweating and pallor
The stroke action plan is: A.FAST B. QUICK C. HURRY D. STOP
A.FAST
The nurse is assessing a patient who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? (Select all that apply) A.Fever B.Positive Cullen's Sign C.Complaints of indigestion D.Palpable mass in the left upper quadrant E.Pain in the upper right quadrant after a fatty meal
A.Fever C.Complaints of indigestion E.Pain in the upper right quadrant after a fatty meal
The nurse is caring for a patient admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would they expect to implement for this patient? (Select all that apply) A.Maintain NPO status. B.Encourage coughing and deep breathing. C.Give small, frequent, high-calorie feedings. D.Give IV Dilaudid as needed for pain. E.Maintain IVF at 10mL/hr
A.Maintain NPO status. C. Give small, frequent, high-calorie feedings. E. Maintain IVF at 10mL/hr
The client diagnosed with chronic kidney disease has been receiving dialysis for 10 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? A. "You cannot just quit your dialysis. This is not an option." B. "You are angry at not being on the list, and you want to quit dialysis?" C. "I will call your nephrologist right now so you can talk to the health care provider." D. "Make you funeral arrangements because you are going to die
B. "You are angry at not being on the list, and you want to quit dialysis?" Reflecting the client's feelings and restating them are therapeutic responses the nurse should use when addressing the client's issues.
Which patient problem has priority for the client diagnosed with acute pancreatitis? A. Risk for fluid volume deficit B. Alteration in comfort C. Imbalanced nutrition: less than body requirements D. Knowledge deficit
B. Alteration in comfort
A nurse is reviewing the serum laboratory dart of s oakfield who has an acute exacerbation of Pre He's disease. Which of the following laboratory tests should the nurse expect to be elevated? (Select all that apply) A.Calcium B. Bryh Royle Sedimentation reite (ES)R) C. WBC D. Folle Acid E. Albumin
B. Bryh Royle Sedimentation reite (ES)R) C. WBC
A nurse is completing discharge teaching with a patient who has Cohn's disease. Which of the following instructions should the nurse include in the teaching? A. Decrease intake of calorie-dense foods. B. Drink canned protein supplements. C. Increase intake of high fiber foods. D. Take a bulk-forming laxative daily.
B. Drink canned protein supplements.
A nurse is reviewing the laboratory findings for a patient who has an acute exacerbation of Crohn's disease. Which of the following laboratory findings is indicative of Crohn's (Select all that apply) A. Elevated Calcium B. Elevated ESR C. Elevated WBC D. Elevated Folic Acid E. Decreased Albumin
B. Elevated ESR C. Elevated WBC
The nurse is caring for a client diagnosed with a traumatic brain injury and an epidural hematoma. Which nursing intervention should he nurse implement? (Select all that apply) A. Encourage neck flexion B. Ensure the pulse oximeter reading is higher than 93% C. Performing deep nasal suctioning every two hours D. Administer stool softners daily E. Monitor for drainage from nose or ears
B. Ensure the pulse oximeter reading is higher than 93% D. Administer stool softners daily E. Monitor for drainage from nose or ears
A nurse is reviewing client laboratory data. The nurse should recognize which of the following findings is expected for a client who has Stage 4 chronic kidney disease? A. Blood urea nitrogen (BUN) 15 mg/dL B. Glomerular filtration rate (GFR) 20 ml/min C. Serum creatinine 1.1 mg/dl D. Serum potassium 5.0 mEq/L
B. Glomerular filtration rate (GFR) 20 ml/min The GFR is severely decreased to approximately 20 mL/min, which is indicative of stage 4 chronic kidney disease
Right brain strokes typically have symptoms on: A. Right side B. Left side C. Both sides D. No motor deficits
B. Left side
Which assessment data should the nurse expect to observe for the patient diagnosed with Parkinson's disease? A. Ascending paralysis and pain B. Masklike facial expression and pill rolling C. Diplopia and ptosis D. Dysphagia and dysarthria
B. Masklike facial expression and pill rolling
The nurse is providing care for a patient with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? A. Stoma is beefy red and shiny B. Purple discoloration of the stoma C. Skin excoriation around the stoma D. Semi-formed stool noted in the ostomy pouch
B. Purple discoloration of the stoma
Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? A. Airborne Precautions B. Standard Precautions C. Droplet Precautions D. Exposure Precautions
B. Standard Precautions
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A. A negative Kernig's sign B. Absence of nuchal rigidity C. A positive Brudzinekle sign D. A Glasgow Some Scale score of 15
C. A positive Brudzinekle sign
A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? A. Administer an opioid medication B. Monitor for hypertension C. Assess level of consciousness D. Increase the dialysis exchange rate
C. Assess level of consciousness C - The nurse should assess the client's level of consciousness. A change in urea levels can cause increased intracranial pressure. Subsequently, the client's level of consciousness decreases
What is the type of stroke with bleeding? A. Embolic B. Thrombotic C. Hemorrhagic D. Meningitic
C. Hemorrhagic
A nurse is assessing a patient who has been taking prednisone following an exacerbation of inflammatory bowel disease (BD). The nurse should recognize which of the following findings as the priority? A.Patient reports difficulty sleeping. B.The patient's urine is positive for glucose C. Patient reports having an elevated body temperature. D.Patient reports gaining 4lb in the last 6 months
C. Patient reports having an elevated body temperature.
Which intervention should the nurse take with the patient recently diagnosed with ALS? A. Discuss a percutaneous gastrostomy tube B. Explain how a fistula is accessed C. Provide an advance directive D. Refer to a physical therapist for leg braces
C. Provide an advance directive
The client diagnosed with acute renal failure (ARF) is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level? A. Erythropoietin B. Calcium gluconate C. Regular insulin D. Osmotic diuretic
C. Regular insulin Regular insulin, along with glucose, will drive potassium into the cells thereby lowering serum potassium levels temporarily
A 75 y.o. The client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (t-PA) B. Discuss the precipitating factors that caused the symptoms C. Schedule for a STAT computed tomography (CT) scan of the head D. Notify the speech pathologist for an emergency consult
C. Schedule for a STAT computed tomography (CT) scan of the head A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment
The patient is admitted to the medical department with a diagnosis of R/O acute pancreatitis. Which laboratory values should the nurse monitor to confirm this diagnosis? A. Creatinine and BUN B. Troponin and CK-MB C. Serum amylase and lipase D. Serum bilirubin and calcium
C. Serum amylase and lipase
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. What action by the UAP requires the nurse to intervene? A. The assistant places a gait belt around the client's waist prior to ambulating B. The assistant places the client on the back with the client's head to the side C. The assistant places a hand under the client's right axilla to move up in bed. D. The assistant praises the client for attempting to perform ADLs independently.
C. The assistant places a hand under the client's right axilla to move up in bed. This action is inappropriate and would required intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation ; the client should be pulled up by placing the arm underneath the back or using a lift sheet
A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that A. chemotherapy will begin after the patient recovers from the surgery. B. both chemotherapy and radiation can be used as palliative treatments. C. follow-up colonoscopies will be needed to ensure that the cancer does not recur. D. A wound, ostomy, and continence nurse will visit the patient to identify an abdominal site for the ostomy.
C. follow-up colonoscopies will be needed to ensure that the cancer does not recur.
The nurse has instructed the family of a client with a stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? A. "We need to discourage him from wearing eyeglasses B. "We need to place objects in his impaired field of vision. C. We need to approach him from the impaired field of vision* D. "We need to remind him to turn his head to scan the lost visual field."
D. "We need to remind him to turn his head to scan the lost visual field."
The best nutritional therapy plan for a person who is obese is A. The Zone diet B. The Atkins diet C. Sugar Busters diet D. A well balanced diet using the food pyramid as a guide
D. A well balanced diet using the food pyramid as a guide
This bariatric surgical procedure involves creating a gustle pouch that is reversible and no malabsorption occurs. What surgical procedure is this? A. Vertical gastric banding B. Biliopancreatic diversion C. RouX en Y gastric bypass D. Adjustable gastric banding
D. Adjustable gastric banding
Treatments for increased ICP may include: A. Elevate HOB B. Hyperventilate to remove CO2 C.Give oxygen to maintain cerebral oxygenation D. All of the above
D. All of the above
The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting MOST successfully? A. Gets angry with family if they interrupt a task B. Experiences bouts of depression and irritability C. Has difficulty with using modified feeding utensils D. Consistently uses adaptive equipment in dressing polf
D. Consistently uses adaptive equipment in dressing polf
The nurse is developing a nursing care plan for the client diagnosed with chronic kidney disease (CKD). Which nursing problem is a priority for the client? A. Low self-esteem B. Knowledge deficit C. Activity intolerance D. Excess fluid volume
D. Excess fluid volume Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death
A Client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid was present? A. Fluid is clear and tests negative for glucose B. Fluid is grossly bloody in appearance and has a uH of 6 C. Fluid slumps together on the dressing and has a pH of 7 D. Fluid separates into concentric rings and tests positive for gLUCOSE
D. Fluid separates into concentris rings and tests postive for gLUCOSE
A nurse is teaching a client who has chronic kidney disease and is to begin hemodialysis. Which of the following information should the nurse include in the teaching? A. Hemodialysis restores kidney function B. Hemodialysis replaces hormonal function of the renal system C. Hemodialysis allows an unrestricted diet D. Hemodialysis returns a balance to serum electrolytes
D. Hemodialysis returns a balance to serum electrolytes The nurse should explain to the client that hemodialysis restores electrolyte balance by removing excess sodium, potassium, fluids, and waste products and also restores acid-base balance
The client diagnosed with acute renal failure (ARF) has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client? A. Administer a phosphate binder. B. Type and crossmatch for whole blood. C. Assess the client for leg cramps. D. Prepare the client for dialysis
D. Prepare the client for dialysis Normal potassium level is 3.5 to 5 mEq/L. A level of 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to decrease the potassium level quickly. This requires a health-care provider order, so it is a collaborative intervention.
The nurse and LPN on a medical unit are caring for a patient with GBS. Which instructions should the nurse provide the LPN? A. Instruct the LPN to call the nurse for assistance when getting the patient out of bed. B. Have the LPN assess the patient for cogwheel motion, rigidity, and dysphagia. C. Discuss the symptom of sudden severe unilateral facial pain with the LPN. D. Tell the LPN to notify the nurse if the patient becomes short of breath.
D. Tell the LPN to notify the nurse if the patient becomes short of breath.
The nurse is assessing a 48 year old patient diagnosed with MS. Which clinical manifestation warrants immediate intervention? A. The patient has scanning speech and diplopia. B. The patient has vertigo and tinnitus. C. The patient has muscle weakness and spasticity. D. The patient has a congested cough and dysphagia
D. The patient has a congested cough and dysphagia
A patient with extreme obesity has undergone Roux-en Y gastric bypass surgery. In planning postoperative care, the nurse anticipates that the patient A. may have severe diarrhea early in the postoperative period. B. will not be allowed to ambulate for 1 to 2 days postoperatively. C. will require a nasogastric suction until the drainage is pale yellow. D. may only have liquids orally, and in very limited amounts, during the early postoperative period.
D. may only have liquids orally, and in very limited amounts, during the early postoperative period.
The nurse is teaching the husband of a woman diagnosed with Alzheimer disease about home care. Which intervention should the nurse discuss with the patient's husband?
Discuss the importance of providing a consistent environment
The nurse and the UAP are caring for patients on a medical surgical unit. Which task would be the most appropriate to assign to the UAP?
Feed the patient with Parkinson disease who has tremors of the hand
A nurse is caring for a patient who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?
Give the patient extra time to perform activities
The nurse and UAP are caring for a patient diagnosed with an acute exacerbation of MS who is receiving soli-medrol, a glucocorticosteriod, intravenous push (IVP) every 6 hours. Which nursing intervention should the nurse delegate to the UAP?
Obtain a bedside glucose test before meals
A nurse is assessing a patient for manifestations of Parkinson's disease. Which of the following are expected findings? SATA
Pill-rolling tremors of the fingers Shuffling gait Drooling Lack of facial expression
A nurse is making a home visit to a patient with who has Alzheimer's disease. The patient's partner states that the patient is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? SATA
Remove floor rugs Provide increased lighting in stairwells Install handrails in the bathroom Place a GPS tracker on the patient's belt
The client with CKD (chronic kidney disease) is placed on a fluid restriction of 1,500 ml/day. On the 7 a.m. to 7 p.m. shift the client drank and eight ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client?
The client drank 26 ounces of fluid (8+4+12+2) or 780 ml (26 x 30). Therefore the client can have 720 ml (1,500-780=720) on the 7 p.m. to 7.a.m. shift.
Acute kidney injury is defined as: a. A sudden cessation of kidney function that occurs when blood flow to the kidneys is significantly comprised b. A long period of progressive loss of kidney function c. Resulting from uncontrolled diabetes that has occurred for past years d. Gradual loss of red blood cells in the renal cavity
a. A sudden cessation of kidney function that occurs when blood flow to the kidneys is significantly comprised
The nurse is assessing a patient with a knife wound to the abdomen. What is a collaboration intervention that the nurse would take to prevent acute renal failure with this patient? a. Administer normal saline IV b. Take vital signs c. Place the patient on telemetry d. Check the abdominal dressing
a. Administer normal saline IV
The leading causes of chronic kidney disease are: a. Hypertension and Diabetes b. Cancer and Alcoholism c. Cirrhosis and Gastritis d. Trauma and Infections
a. Hypertension and Diabetes
Peritoneal dialysis is done by: a. Inserting a catheter through the anterior abdominal wall and infusing fluid into the abdominal cavity b. Inserting a catheter in the arteriovenous fistula and connecting to a dialysis machine c. Inserting a catheter into the femoral artery and linking to a dialyzer d. Inserting a catheter into the bladder and monitoring urine output
a. Inserting a catheter through the anterior abdominal wall and infusing fluid into the abdominal cavity
True or false, a client with atrial fibrillation could develop a thrombotic and/or embolic stroke a. TRUE b. FALSE
a. TRUE
True or False - An arteriovenous vascular access for a hemodialysis patient, connects an artery and a vein together either directly or by graft. a. True b. False
a. True
5. What lab values are most significant for diagnosing Acute Renal Failure: a. Hemoglobin and Hematocrit b. BUN and Creatinine c. Amylase and Lipase d. Troponin and CPK
b. BUN and Creatinine
treatment of obesity, the nurse determines that additional teaching is needed when the patient says a."I shouldn't eat concentrated sweets." b."I can eat small, frequent meals throughout the day." c."I should drink several glasses of fluids with my meals." d."I will need to have a cobalamin injection once a month."
c."I should drink several glasses of fluids with my meals."
The client with chronic renal failure (chronic kidney disease) is placed on a fluid restriction of 1,500 mL/day. On the 7a to 7p shift, the client drank a 10 oz cup of tea, drank 4 oz of juice, drank 12 oz coffee, and drank 2 oz water with medications. What amount of fluid can the 7p to 7 a shift nurse give to the client? a. 440 mL b. 550 mL c. 660 mL d. 770 mL
d. 770 mL
Dietary restriction for chronic kidney patients includes which of the following? a. Potassium restriction b. Phosphorus restriction c. Sodium restriction d. All of the answers
d. All of the answers
The most serious electrolyte imbalance, that can cause cardiac dysrhythmias in chronic renal patients involves which electrolyte: a. Chloride b. Phosphorus c. Albumin d. Potassium
d. Potassium
What is the last stage of Chronic Kidney Disease in which there is kidney failure with little or no glomerular filtration (less than 15 mL/min)? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Stage 5
e. Stage 5