burns & gi hesi practice

A client taking calcium carbonate chewable tablets and ranitidine is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment? 1. Gastric pH of 3 2.Absence of abdominal discomfort 3.GI drainage that is guaiac negative 4.Presence of hypoactive bowel sounds

1

The nurse instructs a client about continuous ambulatory peritoneal dialysis (CAPD). Which statement by the client indicates an accurate understanding of CAPD? 1. "No machinery is involved, and I can pursue my usual activities." 2."A cycling machine is used, so the risk for infection is minimized." 3."The drainage system can be used once during the day and a cycling machine for 3 cycles at night." 4."A portable hemodialysis machine is used so that I will be able to ambulate during the treatment."

1

A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous fistula for access. The client asks the nurse what complications can occur with the access site. What complications should the nurse inform the client about? Select all that apply 1. Hepatitis 2.Infection 3.Hypertension 4.Muscle cramping 5.Post-treatment blood clots

1 & 2

when inflammation occurs, the WBC count is usually

15,000-20,000/mm

The nurse is caring for a client with acute kidney injury (AKI). The nurse should test the client's urine for proteinuria to determine which type of AKI? 1. Prerenal 2.Intrinsic 3.Atypical 4.Postrenal

2

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? 1. Disorientation to time only 2.Heart rate of 95 beats/minute 3.+1 palpable peripheral pulses 4.Urine output of 30 mL over the past 2 hours

2 Usually the UO will be the best indicator for adequate fluid resuscitation

The nurse is planning a teaching session with a client who has chronic kidney disease (CKD) about managing the condition between dialysis treatments. The nurse should plan to include the instruction that weight gain between dialysis treatments should be ideally what value?

2-3 LBS

An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be?

22.5 Rationale: According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%.

The registered nurse is instructing a new nursing graduate about hemodialysis. Which statement made by the new nursing graduate indicates an understanding of the procedure for hemodialysis? Select all that apply. 1. "Sterile dialysate must be used." 2."Dialysate contains metabolic waste products." 3."Heparin sodium is administered during dialysis." 4."Dialysis cleanses the blood of accumulated waste products." 5."Warming the dialysate increases the efficiency of diffusion."

3, 4, 5

A client undergoing hemodialysis is at risk for bleeding from the heparin used during the hemodialysis treatment. The nurse assesses for this occurrence by periodically checking the results of which laboratory test? 1. Bleeding time 2.Thrombin time 3.Prothrombin time (PT) 4.Partial thromboplastin time (PTT)

4

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary? 1. Pallor of all extremities 2.Pulse oximetry reading of 93% 3.Peripheral pulses are diminished 4.High pressure alarm keeps sounding on the ventilator

4

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? 1. Monitor the client. 2. Elevate the head of the bed. 3. Assess the fistula site and dressing. 4. Notify the primary health care provider (PHCP).

4

A week after kidney transplantation, a client develops a temperature of 101º F (38.3º C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? 1. Antibiotic therapy 2. Peritoneal dialysis 3. Removal of the transplanted kidney 4. Increased immunosuppression therapy

4 if it had been within 48 hrs, the kidney would have needed to be removed

in an adult, the normal WBC count is

5,000-10,000/mm

A client undergoing hemodialysis begins to experience muscle cramping. What is the best action by the hemodialysis nurse in this situation?

Decrease the ultrafiltration rate

The nurse has completed teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse should determine that education was effective if the client states to record which parameters daily?

I & O & weights

The nurse checks the serum myoglobin level for a client with a crush injury to the right lower leg because the client is at risk for developing which type of acute kidney injury?

Intrarenal

he nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?

hyperglycemia

A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When should the nurse plan to administer this medication?

on return from dialysis

The nurse is preparing to care for a client receiving peritoneal dialysis. Which should be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis?

strict aseptic technique

A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? 1. Biobrane 2.Autograft 3.Xenograft 4.Homograft

2

The nurse is caring for a client with acute kidney injury (AKI) experiencing metabolic acidosis. When performing an assessment, the nurse should expect to note which breathing pattern 1. Apnea 2.Kussmaul respirations 3.Decreased respirations 4.Cheyne-Stokes respirations

2

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? 1. Eschar 2.Intact blisters 3.Liquefaction necrosis 4.Cherry-red, firm tissue

3

A client with an arteriovenous fistula in the left arm who is undergoing hemodialysis is at risk for infection. Which should the nurse formulate as the best outcome goal for this client problem? 1. The client washes hands at least once per day. 2.The client's temperature remains lower than 101º F (38.3º C). 3.The client avoids blood pressure (BP) measurement in the left arm. 4.The client's white blood cell (WBC) count remains within normal limits.

4

A client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. Which is the priority nursing intervention? 1. Check the shunt for the presence of bruit and thrill. 2.Observe the site once during the shift as time permits. 3.Check the results of the prothrombin time as they are determined. 4.Ensure that small clamps are attached to the arteriovenous shunt dressing.

4

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? 1. The entire period of time during which rehabilitation occurs 2.The period from the time the client is stable to the time when all burns are covered with skin 3.The period from the time the burn was incurred to the time when the client is admitted to the hospital 4.The period from the time the burn was incurred to the time when the client is considered physiologically stable

4

A client who is undergoing peritoneal dialysis calls the nurse at the renal unit and reports the presence of severe abdominal pain and diarrhea. The client also informs the nurse that the peritoneal dialysis returns are brown-tinged in color. Which would the nurse suspect?

bowel perforation

The nurse is monitoring the urine output of a client with a low serum protein level and urinary output less than 30 mL in the last hour. Based on these data, the nurse understands that low urinary output is caused by which force within the kidneys?

oncotic

The nurse is providing instructions regarding the complications of peritoneal dialysis. The nurse emphasizes that onset of peritonitis, a serious complication, is most likely to be associated with which clinical manifestation? 1. Fever 2.Fatigue 3.Clear dialysate output 4.Leaking around the catheter site

1

The nurse is working on a medical-surgical nursing unit and is caring for several clients with chronic kidney disease. The nurse interprets that which client is best suited for peritoneal dialysis as a treatment option? 1. A client with severe heart failure 2.A client with a history of ruptured diverticula 3.A client with a history of herniated lumbar disk 4.A client with a history of 3 previous abdominal surgeries

1

Which finding noted in the client on continuous ambulatory peritoneal dialysis (CAPD) should be reported to the primary health care provider (PHCP)? 1. Cloudy yellow dialysate output 2.Client refusal to take the stool softener 3.Previous evening's dwell time of 8 hours 4.Peritoneal catheter site is not red, and the skin has grown around the cuff

1

A client is about to begin hemodialysis. Which measures should the nurse employ in the care of the client? Select all that apply. 1. Using sterile technique for needle insertion 2.Using standard precautions in the care of the client 3.Giving the client a mask to wear during connection to the machine 4.Wearing full protective clothing such as goggles, mask, gloves, and apron 5.Covering the connection site with a bath blanket to enhance extremity warmth

1, 2, 3, 4

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. 1. Check the level of the drainage bag. 2.Reposition the client to his or her side. 3.Place the client in good body alignment. 4.Check the peritoneal dialysis system for kinks. 5.Contact the primary health care provider (PHCP). 6.Increase the flow rate of the peritoneal dialysis solution.

1, 2, 3, 4

the nurse is performing assessment on a client with acute kidney injury who is in the oliguric phase. Which should the nurse expect to note? Select all that apply. 1. Increased serum creatinine level 2.A low and fixed specific gravity 3.Increased blood urea nitrogen (BUN) level 4.A urine output of 600 to 800 mL in a 24-hour period 5.Urine osmolarity of approximately 300 mOsm/kg (300 mmol/kg)

1, 2, 3, 5

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that apply. 1. Place the client on a cardiac monitor. 2.Notify the primary health care provider (PHCP). 3.Put the client on NPO (nothing by mouth) status except for ice chips. 4.Review the client's medications to determine if any contain or retain potassium. 5.Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.

1, 2, 4

A client diagnosed with chronic kidney disease (CKD) is scheduled to begin hemodialysis. The nurse determines that which neurological and psychosocial manifestations, if exhibited by this client, are related to the CKD? Select all that apply. 1. Agitation 2.Euphoria 3.Depression 4.Withdrawal 5.Labile emotions

1, 3, 4, 5

A client has developed acute kidney injury (AKI) as a complication of glomerulonephritis. Which should the nurse expect to observe in the client? 1. Bradycardia 2.Hypertension 3.Decreased cardiac output 4.Decreased central venous pressure

2

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? 1. Superficial 2.Full-thickness 3.Deep partial-thickness 4.Partial-thickness superficial

2

A client who is performing peritoneal dialysis at home calls the clinic and reports that the outflow from the dialysis catheter seems to be decreasing in amount. The clinic nurse should ask which question first? 1. Have you had any diarrhea?" 2."Have you been constipated recently?" 3."Have you had any abdominal discomfort?" 4."Have you had an increased amount of flatulence

2

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1. Vital signs 2.Urine output 3.Mental status 4.Peripheral pulse

2

The nursing student is assigned to care for a client with a diagnosis of acute kidney injury (AKI), diuretic phase. The nursing instructor asks the student about the primary goal of the treatment plan for this client. Which goal, if stated by the nursing student, indicates an adequate understanding of the treatment plan for this client? 1. Prevent fluid overload. 2.Prevent loss of electrolytes. 3.Promote the excretion of wastes. 4.Reduce the urine specific gravity.

2

A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the following day. The client says to the nurse, "I'll be so happy when the fistula is made tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which interpretation should the nurse make based on the client's statement? 1. The client has an accurate understanding of the procedure and aftercare. 2.The client does not realize how painful removal of the dialysis catheter will be. 3.The client does not understand that the site needs to mature or develop for 1 to 2 weeks before use. 4.The client is not aware that the alternative access site is left in place prophylactically for 2 months.

3

The nurse instructor is evaluating a nursing student for knowledge regarding care of a client with acute kidney injury. Which statement by the student demonstrates the need for further teaching about the diuretic phase of acute kidney injury? 1. The increase in urine output indicates the return of some renal function." 2."The diuretic phase develops about 14 days after the initial insult and lasts about 10 days." 3."The diuretic phase is characterized by an increase in urine output of about 500 mL in a 24-hour period." 4."The blood urea nitrogen and creatinine levels will continue to rise during the first few days of diuresis.

3

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1. Out-of-bed activities 2.Bathroom privileges 3.Immobilization of the affected leg 4.Placing the affected leg in a dependent position

3

The nurse is creating a plan of care for a client with chronic kidney disease and uremia. The nurse is developing interventions to assist in promoting an increased dietary intake while at the same time maintaining necessary dietary restrictions. Which action should the nurse include in the plan of care? 1. Increase the amount of protein in the diet. 2.Increase the amount of potassium in the daily diet. 3.Maintain a diet high in calories with frequent snacks. 4.Encourage the client to eat a large breakfast and smaller meals later in the day.

3

The nurse is preparing to perform a discharge teaching with a client who is started on hemodialysis. Which information should the nurse provide regarding the hemodialysis schedule? 1. 5 hours of treatment, 2 days per week 2. 2 hours of treatment, 6 days per week 3. 3 to 4 hours of treatment, 3 days per week 4. 2 to 3 hours of treatment, 5 days per week

3

The nurse is reviewing the list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse should base the response on knowing that which is the action of the glucose in the solution? 1. Decreases the risk of peritonitis 2.Prevents disequilibrium syndrome 3.Increases osmotic pressure to produce ultrafiltration 4.Prevents excess glucose from being removed from the client

3

The nurse measures the cardiac output of a client and finds it to be 6 L/min. Which amount of kidney perfusion should the nurse anticipate 1. 100 to 300 mL/min 2.500 to 1000 mL/min 3.1200 to 1500 mL/min 4.2000 to 2500 mL/min

3

A client with chronic kidney disease (CKD) has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse determines that these assessment data are compatible with which condition? 1. Advancing uremia 2.Phosphate overdose 3. Folic acid deficiency 4.Aluminum intoxication

4

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? 1. Warmth, redness, and pain in the left hand 2.Ecchymosis and audible bruit over the fistula 3.Edema and reddish discoloration of the left arm 4.Pallor, diminished pulse, and pain in the left hand

4

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1. Hypertension, tachycardia, and fever 2.Hypotension, bradycardia, and hypothermia 3.Restlessness, irritability, and generalized weakness 4.Headache, deteriorating level of consciousness, and twitching

4

The nurse is analyzing the posthemodialysis laboratory test results for a client with chronic kidney disease. The nurse interprets that the dialysis is having an expected but nontherapeutic effect if which value is decreased? 1. Potassium 2.Creatinine 3.Phosphorus 4.Red blood cell (RBC) count

4

The nurse is caring for a client immediately after nephrectomy and renal transplantation. What is the most appropriate datum to use in planning administration of intravenous fluids to this client? 1. A strict hourly rate of 100 mL 2.A strict hourly rate of 150 mL 3.One half of the previous hour's urine output 4.The number of milliliters in the previous hour's urine output

4

The nurse is giving general instructions to a client receiving hemodialysis. Which statement would be most appropriate for the nurse to include? 1. "It is acceptable to eat whatever you want on the day before hemodialysis." 2. "It is acceptable to exceed the fluid restriction on the day before hemodialysis." 3. "Medications should be double-dosed on the morning of hemodialysis because of potential loss." 4. "Several types of medications should be withheld on the day of dialysis until after the procedure."

4. Rationale: Many medications are dialyzable, which means that they are extracted from the bloodstream during dialysis. Therefore, many medications may be withheld on the day of dialysis until after the procedure. It is not typical for medications to be double-dosed because there is no way to be certain how much of each medication is cleared by dialysis. Clients receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1. Decreased heart rate 2.Increased urinary output 3.Increased blood pressure 4.Elevated hematocrit levels

4.Elevated hematocrit levels

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage?

54% According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and the right and left arms were burned, according to the rule of nines, the total area involved would be 54%.

A client is being discharged to home while recovering from acute kidney injury (AKI). Reduced dietary intake of which substance indicates to the nurse that the client understands the dietary teaching

potassium

Before providing care for a client in the late stages of chronic kidney disease (CKD), the nurse should review the results of which most relevant laboratory studies?

potassium & calcium