Final

When caring for a group of clients, the nurse recognizes that 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 *Client in the intensive care unit on high doses of antibiotics *Client recovering from gastrointestinal influenza

A large number of victims arrive at the emergency department after a bus is hit by a train. Which interventions are performed immediately for red-tagged victims? (Select all that apply.)

*Intubating a cyanotic client in respiratory distress *Initiating IV fluids for a client with a blood pressure of 96/60 mm Hg and a pulse of 144 beats/min *Attaching an external pacemaker for a client with a heart rate of 44 beats/min

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies clients with which injuries with yellow tags? (Select all that apply.)

*Partial-thickness burns covering both legs *Neck injury and numbness of both legs *Small pieces of shrapnel embedded in both eyes *Bruising and pain in the right lower abdomen

When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? Select all that apply

*Prolonged partial thromboplastin time (PTT) *Icterus of skin *Swollen abdomen

The nurse assists the client with acute kidney injury (AKI) to modify the diet in which way? Select all that apply.

*Restricted protein *Fluid restriction *Low potassium

During a hot summer day, an older adult client tells the clinic nurse, "I am not drinking or voiding that much these days." The nurse notes a heart rate of 100 beats/min and a blood pressure of 90/60 mm Hg. Which action does the nurse take first?

Give the client something to drink.

A client with a decreased glomerular filtration rate asks how to prevent further damage to the kidneys. Which is the nurse's best response?

"Avoid taking NSAIDs."

The nurse is reviewing a client's history. Which statement by the client indicates a need for health teaching?

"Because of my arthritis, I take a lot of Tylenol."

The client with obstructive jaundice asks the nurse why his skin is so itchy. Which is the nurse's best response?

"Bile salts accumulate in the skin and cause the itching."

The client's spouse expresses concern that the client, who has Guillain-Barré syndrome, is becoming very depressed and will not leave the house. What is the nurse's best response?

"Contact the Guillain-Barré Foundation International for resources."

The client experiences low back pain near the end of each day. The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions will the nurse plan to include in teaching the client about preventing low back pain and injury? Select all that apply.

* "Begin a regular exercise program." * "When lifting something, the back should be straight and the knees bent." * "Do not wear high-heeled shoes."

Which are risk factors for stroke? Select all that apply

* High blood pressure * Previous stroke or transient ischemic attack (TIA) * Smoking * Use of oral contraceptives

A client asks the nurse, "What are the advantages of peritoneal dialysis over hemodialysis?" Which response by the nurse is accurate? (Select all that apply.)

*"It will give you greater freedom in your scheduling." *"You do not need a machine to do it." *"You will have fewer dietary restrictions."

A client is admitted to the hospital with a serum creatinine level of 2 mg/dL. When taking the client's history, which question does the nurse ask first?

"Do you take any nonprescription medications?"

The daughter of the client who has had a stroke asks the nurse for additional resources. What is the nurse's best response?

"Go to the National Stroke Association website."

The client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching?

"I can continue to take over-the-counter drugs."

The client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates understanding of the nurse's instruction?

"I can go home the day of the procedure."

The nurse is teaching a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?

"I can go swimming all by myself because I am a certified lifeguard."

A client has been diagnosed with hepatitis A. The nurse evaluates that teaching regarding the disease is understood when the client makes which statement?

"I may have been exposed when we ate shrimp last weekend."

The nurse is teaching the client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates understanding of the nurse's instruction?

"I may still be able to get pregnant."

Which statement by a client with alcohol-induced cirrhosis indicates the need for further teaching?

"I need to avoid protein in my diet."

The client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates correct understanding of the nurse's instruction?

"I should call 911 if a sudden increase in weakness occurs."

Which response by a client indicates an understanding of measures to facilitate the flow of peritoneal dialysate fluid?

"I will take my stool softeners every day."

Which statement by the client with cirrhosis indicates that further instruction is needed about the disease?

"My liver is scarred, but the cells can regenerate themselves and repair the damage."

Which statement by a client who has undergone kidney transplantation indicates a need for more teaching?

"My new kidney is working fine. I do not need to take medications any longer."

The RN has assigned a client with a newly placed arteriovenous (AV) fistula in the right arm to an LPN. Which information about the care of this client is most important for the RN to provide to the LPN?

"Take blood pressure in the left arm."

A client who has chronic kidney disease is being discharged from the hospital after receiving treatment for a hip fracture. Which information is most important for the nurse to provide to the client before discharge?

"Take your aluminum hydroxide (Nephrox) with meals."

Discharge teaching has been provided for the client recovering from kidney transplantation. Which information indicates that the client understands the instructions?

"The anti-rejection medications will be taken for life."

The nurse is providing discharge teaching for a client who will be receiving pancreatic enzyme replacement at home. Which statement by the client indicates that additional teaching is needed?

"The best time to take the enzymes is immediately after I have a meal or a snack."

The 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?

"What concerns do you have about your kidney disease?"

After losing her home to a hurricane several years ago, the client says, "I get very nervous during a thunderstorm and want to hide under the bed." What is the nurse's best response?

"What do you do when you feel this way?"

The nurse is working with a paramedic who just finished assisting at the scene of a school shooting where several students were killed. Which statement by the nurse is most therapeutic?

"Would you like to talk about what happened?"

A client with acute kidney failure and on dialysis asks how much fluid will be permitted each day. Which is the nurse's best response?

"You can drink an amount equal to your urine output, plus 700 mL."

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at the nurse when dinner is served late. What is the nurse's best response?

"You seem upset. I have time to talk if you like."

The nurse is providing dietary teaching to a client who was just started on peritoneal dialysis (PD). Which instruction does the nurse provide to this client regarding protein intake?

"You will need more protein now because some protein is lost by dialysis."

When caring for the client with a left forearm arteriovenous (AV) fistula created for hemodialysis, the nurse must do which of these? Select all that apply.

*Auscultate for a bruit each shift. *Teach the client to palpate for a thrill over the site *Ensure that no blood pressures are taken in that arm.

The client is being evaluated for signs associated with myasthenia crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis?

Abdominal cramps, blurred vision, facial muscle twitching

A client with acute kidney injury is placed on a fluid restriction. To determine whether outcomes related to fluid balance are being met, the nurse assesses for which finding?

Absence of lung crackles

The emergency department nurse assesses a middle-aged mountain climber who reports headache, nausea, vomiting, and "feeling winded." What is the nurse's priority intervention?

Administer acetazolamide (Diamox).

When evaluating the effects of a low-protein diet in a client with chronic kidney disease, the nurse is most concerned with which result?

Albumin level of 2 g/dL

The emergency department nurse assesses a client in extreme pain with an apparent snakebite of the leg. Vital signs are stable. What is the priority action of the nurse?

Apply an immobilization splint.

The hospital is overwhelmed when caring for victims after an earthquake that occurred 48 hours ago. Which responsibility of the nursing supervisor is most important at this time?

Arranging relief and coordinating breaks so nursing staff can rest and eat

The nurse is caring for a client who had a near-drowning incident in a lake. Which action will the nurse take to monitor for possible complications?

Assess the client's temperature every 4 hours.

The nurse is caring for a drowning victim after resuscitation. What focused assessment will the nurse perform to identify complications from drowning?

Auscultation of lungs

The 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

A young man comes into the foyer of the hospital and says that he has a container of anthrax, which he opens and pours on the floor. Which is the priority action for the nurse who first comes upon the scene?

Begin to evacuate the immediate area.

The nurse encourages the ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique?

Blinking for "yes" or "no"

Which client is most at risk for developing postrenal kidney failure?

Client diagnosed with renal calculi

The nurse is providing a client with a peritoneal dialysis exchange. The nurse notes the presence of cloudy peritoneal effluent. Which action by the nurse is most appropriate?

Collect a sample to send to the laboratory.

A client's temperature after dialysis is 99° F (37.2° C) and was normal before dialysis. Which is the nurse's best action?

Continue to monitor the temperature.

The client recovering from a stroke reports double vision that is preventing him from effectively completing activities of daily living. How does the nurse help the client compensate?

Covers the affected eye

Which is the priority action for the emergency department charge nurse in the event of a mass casualty situation?

Directing medical-surgical and critical care nurses to assist with clients who are already in the ED while the ED staff prepares to receive the mass casualty victims

A client has been missing some scheduled hemodialysis sessions. Which intervention is most important for the nurse to implement?

Discussing with the client his or her acceptance of the disease

A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which treatment will the nurse prepare for this client?

Dry clothing and warm blankets

The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results?

Elevated lipase, elevated white blood cell count, elevated glucose

Which laboratory findings does the nurse recognize as potentially causing complications of liver disease?

Elevated prothrombin time and international normalized ratio (INR)

Which laboratory data does the nurse correlate with advanced disease in a client with cirrhosis?

Elevated serum ammonia level

Which activity by the nurse will best relieve symptoms associated with ascites?

Elevating the head of the bed

A client has been diagnosed with acute postrenal kidney injury. Which assessment finding does the nurse assess most carefully for?

Feeling of urgency

In addition to frequent repositioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury?

Gel pad

The nurse working at a first aid booth during a summer marathon sees several runners. Which runner should be seen first? A runner who:

Has fallen several times

A client who is 2 days post-femoral vein cannulation begins to have difficulty with outflow of blood during dialysis. For which complication does the nurse assess?

Hematoma at cannula insertion site

A client is scheduled to have dialysis in 30 minutes and is due for the following medications: vitamin C, B-complex vitamin, and cimetidine (Tagamet). Which action by the nurse is best?

Hold all medications until after dialysis.

A client has a serum creatinine level of 2.5 mg/dL, a serum potassium level of 6 mmol/L, an arterial pH of 7.32, and a urine output of 250 mL/day. Which phase of acute kidney failure is the client experiencing?

Oliguric

The client has been admitted with a diagnosis of cerebrovascular incident. The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms?

Impulsiveness and smiling

A client is taking furosemide (Lasix). To detect a common adverse effect, the nurse obtains which assessment as a priority?

Intake and output

On a hot, humid day, several clients present to the emergency department with symptoms of heat exposure. Which client will be treated first? A client who:

Is anxious and confused

The nurse is caring for a client with acute pancreatitis. Which nursing intervention best reduces discomfort for the client?

Maintaining NPO status for the client with IV fluids

An industrial accident has occurred near the hospital, and many victims are brought to the emergency department (ED) for treatment of their injuries. The nurse triages the victim with which injury with a red tag?

Multiple fractured ribs and shortness of breath

A client has a serum creatinine level of 2 mg/dL and a urine output of 1000 mL/day. How does the nurse categorize the client's kidney injury?

Nonoliguric

The nurse teaches the client recovering from acute kidney disease to avoid which of these?

Nonsteroidal anti-inflammatory drugs

When providing discharge teaching to the client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these?

Nonsteroidal anti-inflammatory drugs

The nurse is working in the emergency department on a hot, humid day, when a hiker is brought in after collapsing. The hiker is confused and tachycardic with a temperature of 105.6° F (40.9° C). Which IV solution and medication will the nurse have ready for the client?

Normal saline and lorazepam (Ativan)

The nurse has been assigned the role of triage nurse after a weather-related disaster. What is the priority action of the nurse?

Perform a rapid assessment of clients to determine priority of care.

A client is receiving follow-up care after surviving a tornado. The client reports insomnia and the nurse notes that the client jumped as the nurse entered the room. Which action by the nurse is most appropriate?

Perform additional assessments for post-traumatic stress disorder.

The client is admitted with a spinal cord injury at the fifth thoracic vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care?

Positioning the client to maximize ventilation potential

Which problem for the client with cirrhosis takes priority?

Potential for injury related to hemorrhage

During hemodialysis, a client with chronic kidney disease develops headache, nausea, vomiting, and restlessness. After notifying the health care provider, which action by the nurse is most appropriate?

Prepare to administer phenytoin (Dilantin),

A client was just admitted to the emergency department for new-onset confusion. As the nurse starts the IV line, the client says he just finished a hemodialysis session. The IV site is bleeding briskly. What action by the nurse takes priority?

Prepare to administer protamine sulfate.

Assessment findings reveal that a client with chronic kidney disease is refusing to take prescribed medications because of the "cost." The client also is having difficulty performing activities of daily living and prefers to sleep most of the day. To which health care team member does the nurse refer the client?

Psychiatric nurse practitioner

An accident has occurred near the hospital, and a victim is brought to the emergency department with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60 mm Hg, and a respiratory rate of 28 breaths/min. The nurse assesses shortness of breath and diaphoresis. Which color tag does the nurse use when triaging this client?

Red

Which staff member does the charge nurse assign to care for a client newly diagnosed with chronic kidney disease?

Registered nurse who has taken care of this client before

Which intervention is most important for the nurse to implement in a client after kidney transplant surgery?

Remove the indwelling (Foley) catheter as soon as possible.

The nurse is assessing a client recently bitten by a coral snake. Which assessment is the priority?

Respiratory rate and depth

A client with chronic kidney disease is scheduled to be given the following medications: digoxin (Lanoxin) and epoetin alfa (Epogen). The client reports nausea and vomiting and wishes to wait to take the medications. Which action by the nurse is most appropriate?

Review today's potassium level and notify the health care provider.

The nurse is providing emergency care to a client with frostbite. Which intervention is performed first?

Rewarm the affected area in a 104° F water bath.

When providing care for a client receiving peritoneal dialysis, the nurse notices that the effluent is cloudy. Which intervention is most important for the nurse to carry out?

Send a specimen for culture and sensitivity

A client with chronic hypertension is seen in the clinic. Which assessment indicates that the client's hypertension is not under control?

Serum creatinine level of 1.9 mg/dL

A client is receiving continuous arteriovenous hemofiltration (CAVH). Which laboratory value does the nurse monitor most closely?

Sodium

The client is being discharged with paraplegia secondary to a motor vehicle accident and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client?

Spinal Cord Injury Hotline

The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priority action of the nurse?

Sponge the victim with cool water and remove his shirt.

A client is admitted with a 3-day history of vomiting and diarrhea. The client's vital signs are blood pressure, 85/60 mm Hg; and heart rate, 105 beats/min. Which intervention by the nurse takes priority?

Start an IV of normal saline as ordered.

During a mass casualty, which injury receives care first?

Sucking chest wound

The client comes to the emergency department covered with coagulated blood and a white powder. The client is hysterical and fears that it is anthrax. What does the nurse do first?

Takes the client to the decontamination room

When caring for the client with acute kidney injury and a temporary subclavian hemodialysis catheter, which of these should the nurse report to the provider?

Temperature 100.8

The emergency department (ED) is expecting a large number of casualties after a bridge collapse. Which is a priority consideration for the ED leadership when activating the disaster plan?

The ED may receive many unexpected victims with minor injuries from the bridge collapse.

Which statement by the nursing student illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)?

The client's respiratory status and muscle function are affected by both diseases.

The nurse is planning care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate?

The regional poison control center

The client in the emergency department (ED) has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms occur during the day with a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing?

Thrombotic stroke

The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase (Cotazym). Which instruction will the nurse include when teaching the client about this medication?

Wipe your lips after taking pancrelipase.