Exam 3

A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it a. is much less likely to clot. b. increases patient mobility. c. can accommodate larger needles. d. can be used sooner after surgery.

ANS: A AV fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.

The nurse is caring for a patient who had kidney transplantation several years ago. Which assessment finding may indicate that the patient is experiencing adverse effects to the prescribed corticosteroid? a. Joint pain b. Tachycardia c. Postural hypotension d. Increase in creatinine level

ANS: A Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not caused by corticosteroid use.

Cobalamin injections have been prescribed for a patient with chronic atrophic gastritis. The nurse determines that teaching regarding the injections has been effective when the patient states, a. "The cobalamin injections will prevent me from becoming anemic." b. "These injections will increase the hydrochloric acid in my stomach." c. "These injections will decrease my risk for developing stomach cancer." d. "The cobalamin injections need to be taken until my inflamed stomach heals."

ANS: A Cobalamin supplementation prevents the development of pernicious anemia. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin.

A patient is hospitalized with vomiting of "coffee-ground" emesis. The nurse will anticipate preparing the patient for a. endoscopy. b. angiography. c. gastric analysis testing. d. barium contrast studies.

ANS: A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding.

Twelve hours after undergoing a gastroduodenostomy (Billroth I), a patient complains of increasing abdominal pain. The patient has absent bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The most appropriate action by the nurse at this time is to a. notify the surgeon. b. irrigate the NG tube. c. administer the prescribed morphine. d. continue to monitor the NG drainage.

ANS: A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. The patient may need morphine, but this is not the highest priority action. Continuing to monitor the NG drainage is not an adequate response.

The nurse has instructed a patient who is receiving hemodialysis about appropriate dietary choices. Which menu choice by the patient indicates that the teaching has been successful? a. Scrambled eggs, English muffin, and apple juice b. Oatmeal with cream, half a banana, and herbal tea c. Split-pea soup, whole-wheat toast, and nonfat milk d. Cheese sandwich, tomato soup, and cranberry juice

ANS: A Scrambled eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.

After the nurse has finished teaching a patient with ulcerative colitis about sulfasalazine (Azulfidine), which patient statement indicates that the teaching has been effective? a. "I will need to use a sunscreen when I am outdoors." b. "I will need to avoid contact with people who are sick." c. "The medication will need to be tapered if I need surgery." d. "The medication will prevent infections that cause the diarrhea."

ANS: A Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

A patient is brought to the emergency department with a knife impaled in the abdomen following a domestic fight. During the initial assessment of the patient, the nurse should a. assess the BP and pulse. b. remove the knife to assess the wound. c. determine the presence of Rovsing sign. d. insert a urinary catheter and assess for hematuria.

ANS: A The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there.

After teaching a patient to irrigate a new colostomy, the nurse will determine that the teaching has been effective if the patient a. hangs the irrigating container about 18 inches above the stoma. b. stops the irrigation and removes the irrigating cone if cramping occurs. c. inserts the irrigation tubing no further than 4 to 6 inches into the stoma. d. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.

ANS: A The irrigating container should be hung 18 to 24 inches above the stoma. If cramping occurs, the irrigation should be temporarily stopped and the cone left in place. Five hundred to 1000 mL of water should be used for irrigation. An irrigation cone, rather than tubing, should be inserted into the stoma; 4 to 6 inches would be too far for safe insertion.

A patient who is diagnosed with nephrotic syndrome has 3+ ankle and leg edema and ascites. Which nursing diagnosis is a priority for the patient? a. Excess fluid volume related to low serum protein levels b. Activity intolerance related to increased weight and fatigue c. Disturbed body image related to peripheral edema and ascites d. Altered nutrition: less than required related to protein restriction

ANS: A The patient has massive edema, so the priority problem at this time is the excess fluid volume. The other nursing diagnoses also are appropriate, but the focus of nursing care should be resolution of the edema and ascites.

A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations about 20 minutes after eating. To avoid recurrence of these symptoms, the nurse teaches the patient to a. lie down for about 30 minutes after eating. b. choose foods that are high in carbohydrates. c. increase the amount of fluid intake with meals. d. drink sugared fluids or eat candy after each meal.

ANS: A The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

In a patient with acute kidney injury (AKI) who requires hemodialysis, a temporary vascular access is obtained by placing a catheter in the left femoral vein. Which intervention will be included in the plan of care? a. Place the patient on bed rest. b. Start continuous pulse oximetry. c. Discontinue the retention catheter. d. Restrict the patient's oral protein intake.

ANS: A The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? a. Check the fistula site for a bruit and thrill. b. Assess the rate and quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

ANS: A The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.

A patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. periodically aspirates and tests gastric pH. b. monitors arterial blood gas values on a daily basis. c. checks each stool for the presence of occult blood. d. measures the amount of residual stomach contents hourly.

ANS: A The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal (GI) bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

A patient who has advanced cirrhosis is receiving lactulose (Cephulac). Which finding by the nurse indicates that the medication is effective? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

ANS: A The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. The nurse explains that the test is used to a. confirm the diagnosis of colon cancer. b. monitor the tumor status after surgery. c. identify the extent of cancer spread or metastasis. d. determine the need for postoperative chemotherapy.

ANS: B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.

A patient who has had a transurethral resection with fulguration for bladder cancer 3 days previously calls the nurse at the urology clinic. Which information given by the patient is most important to report to the health care provider? a. The patient is using opioids for pain. b. The patient has noticed clots in the urine. c. The patient is very anxious about the cancer. d. The patient is voiding every 4 hours at night.

ANS: B Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure.

The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patient complains of feeling bloated after the inflow.

ANS: B Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

To evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which action should the nurse take? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms to the front. c. Instruct the patient to perform the Valsalva maneuver. d. Have the patient walk a few steps with the eyes closed.

ANS: B Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests also might be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

The RN and nursing assistive personnel (NAP) are caring for a patient with a paralytic ileus. Which of these nursing activities is appropriate for the nurse to delegate to NAP? a. Auscultation for bowel sounds b. Applying petroleum jelly to the lips c. Irrigation of the nasogastric (NG) tube with saline d. Assessment of the nose for irritation

ANS: B NAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

After the home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying, which patient statement indicates that the teaching has been effective? a. "I will use a sterile catheter and gloves for each time I self-catheterize." b. "I will clean the catheter carefully before and after each catheterization." c. "I will need to buy seven new catheters weekly and use a new one every day." d. "I will need to take prophylactic antibiotics to prevent any urinary tract infections."

ANS: B Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics.

A patient who has blunt abdominal trauma after an automobile accident is complaining of severe pain. A peritoneal lavage returns brown drainage with fecal material. Which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

A patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) has a serum potassium level of 3.2 mEq/L (3.2 mmol/L). Which action should the nurse take? a. Give both drugs as scheduled. b. Administer the spironolactone. c. Administer the furosemide and withhold the spironolactone. d. Withhold both drugs until talking with the health care provider.

ANS: B Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.

When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient's family that the patient has a history of gastroesophageal reflux disease (GERD). The nurse will plan to do frequent assessments of the patient's a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth.

ANS: C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine

Which nursing action is most important to include in the plan of care for a patient who had an abdominal-perineal resection the previous day? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.

ANS: C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

A patient undergoes a nephrectomy after having massive trauma to the kidney. Which assessment finding obtained postoperatively is most important to communicate to the surgeon? a. Blood pressure is 102/58. b. Incisional pain level is 8/10. c. Urine output is 20 mL/hr for 2 hours. d. Crackles are heard at both lung bases.

ANS: C Because the urine output should be at least 0.5 mL/kg/hr, a 40 mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain.

After the nurse has provided patient teaching about recommended dietary choices for a patient with an acute exacerbation of inflammatory bowel disease (IBD), which diet choice by the patient indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

ANS: C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

The nurse will plan to teach the patient with newly diagnosed achalasia that a. a liquid or blenderized diet will be necessary. b. drinking fluids with meals should be avoided. c. endoscopic procedures may be used for treatment. d. lying down and resting after meals is recommended.

ANS: C Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Patients are advised to drink fluid with meals. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying.

A critically ill patient develops incontinence of watery stools. What action will be best for the nurse to take to prevent complications associated with ongoing incontinence? a. Insert a rectal tube. b. Use incontinence briefs. c. Implement fecal management system. d. Assist the patient to a bedside commode or to the bathroom at frequent intervals.

ANS: C Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. Incontinence briefs may be helpful but, unless they are changed frequently, are likely to increase the risk for skin breakdown. A critically ill patient will not be able to use the commode or bathroom.

When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider? a. Dry lips and oral mucosa b. Crackles at both lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days

ANS: C Infection risk is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions, but do not indicate a need for urgent action.

Following an exploratory laparotomy and bowel resection, a patient who has a nasogastric tube to suction complains of nausea and stomach distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient's health care provider. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider. Information about the presence or absence of bowel tones will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient.

Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the a. blood urea nitrogen (BUN) and creatinine. b. blood glucose level. c. patient's bowel sounds. d. level of consciousness (LOC).

ANS: C Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse's decision to give the medication.

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. antacids 30 minutes before the sucralfate. b. sucralfate at bedtime and antacids before meals. c. antacids after eating and sucralfate 30 minutes before eating. d. sucralfate and antacids together 30 minutes before each meal.

ANS: C Sucralfate is most effective when the pH is low and should not be given with or soon after antacid. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

After a patient has had a transjugular intrahepatic portosystemic shunt (TIPS) placement, which finding indicates that the procedure has been effective? a. Lower indirect bilirubin level b. Increase in serum albumin level c. Decrease in episodes of variceal bleeding d. Improvement in alertness and orientation

ANS: C TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

A patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which of these orders for the patient will the nurse question? a. NPO for 6 hours before IVP procedure b. Normal saline 500 mL IV before procedure c. Ibuprofen (Advil) 400 mg PO PRN for pain d. Dulcolax suppository 4 hours before IVP procedure

ANS: C The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the NSAIDs should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure.

Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The blood urea nitrogen (BUN) and creatinine levels are elevated. c. The patient's central venous pressure (CVP) is decreased. d. The patient has level 8 (on a 10-point scale) incisional pain.

ANS: C The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

When reviewing patient laboratory results, the nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the following four patients. Which patient's PSA result is most important to report to the health care provider? a. A 75-year-old who uses saw palmetto to treat benign prostatic hyperplasia (BPH) b. A 38-year-old who is being treated for acute prostatitis c. A 48-year-old whose father died of metastatic prostate cancer d. A 52-year-old who goes on long bicycle rides every weekend

ANS: C The family history and elevation of PSA in the 48-year-old indicate that further evaluation of the patient for prostate cancer is needed. The elevations in PSA for the other patients are not unusual.

A patient returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. Which nursing action should be included in the plan of care? a. Insist that the patient examine the surgical incision when the dressings are removed. b. Teach the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes. c. Post a sign at the bedside warning against blood pressures or venipunctures in the right arm. d. Obtain a permanent breast prosthesis for the patient before she is discharged from the hospital.

ANS: C The patient is at risk for lymphedema and infection if blood pressures or venipuncture are done on the right arm. The patient is taught to use the PCA as needed for pain control rather than at a set time. The nurse allows the patient to examine the incision and participate in care when the patient feels ready. Permanent breast prostheses are usually obtained about 6 weeks after surgery.

The health care provider plans a paracentesis for a patient with ascites caused by liver cancer. To prepare the patient for the procedure, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

ANS: C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Since no sedation is required for paracentesis, the patient does not need to be NPO.

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to try to get more protein from dairy products." b. "I will try to increase my intake of fruits and vegetables." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take the erythropoietin to boost my immune system and help prevent infection."

ANS: C The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Obtain blood to check the blood urea nitrogen (BUN) level. c. Check the patient's blood pressure. d. Give prescribed PRN antiemetic drugs.

ANS: C The patient's complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions also may be appropriate, based on the blood pressure obtained

Which assessment finding in a patient who had a total gastrectomy 12 hours previously is most important to report to the health care provider? a. Absent bowel sounds b. Scant nasogastric (NG) tube drainage c. Complaints of incisional pain d. Temperature 102.1° F (38.9° C)

ANS: D An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.

Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check the laboratory value for a. creatinine. b. potassium. c. total cholesterol. d. serum phosphate.

ANS: D If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

Which of these nursing actions should the RN working in the emergency department delegate to nursing assistive personnel who help with the care of a patient who has been admitted with nausea and vomiting? a. Auscultate the bowel sounds. b. Assess for signs of dehydration. c. Ask the patient what precipitated the nausea. d. Assist the patient with oral care after vomiting.

ANS: D Oral care is included in nursing assistive personnel education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice.

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient slows the inflow rate when experiencing pain. b. The patient leaves the catheter exit site without a dressing. c. The patient plans 30 to 60 minutes for a dialysate exchange. d. The patient cleans the catheter while taking a bath every day.

ANS: D Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

A patient with acute kidney injury (AKI) has an arterial blood pH of 7.30. The nurse will assess the patient for a. vasodilation. b. poor skin turgor. c. bounding pulses. d. rapid respirations.

ANS: D Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which action should the nurse take first? a. Document the QRS interval. b. Notify the patient's health care provider. c. Look at the patient's current blood urea nitrogen (BUN) and creatinine levels. d. Check the chart for the most recent blood potassium level.

ANS: D The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval also is appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening bradycardia.

A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicate that it is most important for the nurse to monitor the patient's a. hemoglobin. b. temperature. c. activity level. d. albumin level.

ANS: D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters also should be monitored, but they are not directly associated with the patient's current symptoms.

A patient who is vomiting bright red blood is admitted to the emergency department. Which assessment should the nurse perform first? a. Checking the level of consciousness b. Measuring the quantity of any emesis c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding; BP and pulse are the best indicators of these complications. The other information also is important to obtain, but BP and pulse rate are the best indicators for hypoperfusion.

A new order for IV gentamicin (Garamycin) 60 mg BID is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patient's a. urine osmolality. b. serum potassium. c. blood glucose level. d. blood urea nitrogen (BUN) and creatinine.

ANS: D When a patient at risk for chronic kidney disease (CKD) receives a nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in determining the effect of the gentamicin.