Exam 3

Which action is the best intervention for the client with chronic renal failure who is anuric and severely hypertensive? A. hemodialysis treatment B. dietary restrictions C. fluid restrictions D. diuretic therapy

hemodialysis treatment

A client with congestive heart failure and pulmonary edema develops the onset of acute renal failure. Upon examination by the healthcare team, the collaborative plan of care for this client should include which of the following? A. monitoring for blood clots B. replacing fluid volume C. maintaining cardiac output D. diluting nephrotoxic substances

maintaining cardiac output

Which medication has the highest risk for nephrotoxicity? A. anticoagulants B. vitamin supplements C. nonsteroidal anti-inflammatory drugs D. herbal supplements

nonsteroidal anti-inflammatory drugs

Which of the following statements by the client indicates that instruction in ways to prevent urinary tract infections was understood? A. "I should limit drinking water so I wont need to urinate so often" B. "I should drink 8-10 glasses of fluid everyday" C. "I should wear nylon or synthetic undergarments" D. "I will need to urinate every 6 hours while I am awake"

"I should drink 8-10 glasses of fluid everyday"

A client who is 12 hours post embolectomy asks the nurse how to prevent a pulmonary embolism. What is the appropriate response by the nurse? A. "avoid prolonged sitting or standing" B. "do not bend over at the waist" C. "use an incentive spirometer daily" D. "apply ice packs to sites of injury"

"avoid prolonged sitting or standing"

The nurse is teaching a client who has deep vein thrombosis that caused a pulmonary embolus, which has now resolved. what should the nurse tell the client? A. "limit your fluids to 1L each day" B. "walk at least every other day" C. "report signs such as leg swelling, discomfort, redness or warmth" D. "sit with your legs lower than the rest of your body"

"report signs such as leg swelling, discomfort, redness or warmth"

A client being hemodialyzed becomes short of breath, complains of chest pain, and is tachycardia, pale and anxious. The priority action of the nurse is which of the following? A. Discontinue the dialysis and notify the physician B. monitor vital signs every 15 minutes for the hour C. continue dialysis at a slower infusion rate D. bolus the client with 500mL of normal saline

A. Discontinue the dialysis and notify the physician

A nurse understands that the most important use of dialysis is to: A. restore excess body fluids B. maintain electrolyte balance C. eliminate acid-base balance D. maintain toxins in the blood

B. maintain electrolyte balance

Which situation requires immediate intervention by the nruse in a client with an arterial-venous fistula? A. HR 88, BP 85/53, RR 24 B. BUN 44, Creatinine 2.3, K+ 5.1 C. pH 7.33, pCO2 47, HCO3 24 D. HGB 8.8, HCT 20, RBC 4.5

A. HR 88, BP 85/53, RR 24

A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client's oxygen saturation has not significantly improved. What response by the nurse is the best? A. "The blood clot interferes with perfusion to the lungs" B. "Maybe the client has respiratory distress syndrome" C. "Breathing rapidly interferes with oxygenation" D. "The client needs immediate intubation and mechanical ventilation"

A. "The blood clot interferes with perfusion to the lungs"

The nurse is preparing to discharge a client on warfarin. Which health teaching will the nurse include as part of discharge planning related to the client's DVT management and prevention of a new DVT? (Select all that Apply) A. "wear knee high compression stockings" B. "apply prolonged pressure over cuts and nosebleeds" C. "contact your primary healthcare provider if your stool is black and tarry" D. "avoid eating foods that are high in fat and cholesterol" E. "if you miss a dose of warfarin, take a double dose the next day"

A. "wear knee high compression stockings" B. "apply prolonged pressure over cuts and nosebleeds" C. "contact your primary healthcare provider if your stool is black and tarry"

A nurse is caring for several clients. Which of the following clients are at risk for developing pyelonephritis? (Select all that Apply) A. a client who has a neurogenic bladder B. a client who has kidney calculi C. a client who has diabetes mellitus D. a client who has a urine pH of 4.2 E. a client who is 32 weeks gestation

A. a client who has a neurogenic bladder B. a client who has kidney calculi C. a client who has diabetes mellitus E. a client who is 32 weeks gestation

A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect? (Select all that Apply) A. foamy urine B. weight loss C. periorbital edema D. urine dipstick protein +1 E. edema in ankles and feet

A. foamy urine C. periorbital edema E. edema in ankles and feet

The nurse is caring for a client who is experiencing excessive bleeding after receiving unfractionated heparin. What orders does the nurse anticipate from the healthcare provider? (Select all that Apply) A. laboratory draw for activated partial thromboplastin time (aPTT) B. administer vitamin K C. administer protamine sulfate D. laboratory draw for prothrombin time (PT) and international normalized ration (INR) E. administer enoxaparin (Lovenox_

A. laboratory draw for activated partial thromboplastin time (aPTT) B. administer vitamin K C. administer protamine sulfate D. laboratory draw for prothrombin time (PT) and international normalized ration (INR)

Which manifestation, if identified in a post kidney transplantation client during the postoperative period, should a nurse associate with the development of transplant rejection? A. oliguria B. pyuria C. bacteriuria D. dysuria

A. oliguria

Which manifestations if identified in a post kidney transplantation client, would indicate that the kidney transplantation surgery has not been successful? A. oliguria B. bacteriuria C. pyuria D. dysuria

A. oliguria

Which finding indicates a arteriovenous fistula is patent? A. palpation of a thrill over the fistula B. presence of a radial pulse C. absence of bruit on auscultation of fistula D. capillary refill less than 3 seconds

A. palpation of a thrill over the fistula

A nurse is planning care for a client who has chronic pyelonephritis. Which of the following actions should the nurse plan to take? (Select all that Apply) A. provide a referral for nutritional counseling B. Administer antibiotics C. monitor urine output D. palpate the costovertebral angle E. encourage daily fluid intake of 1 liter

A. provide a referral for nutritional counseling B. Administer antibiotics C. monitor urine output D. palpate the costovertebral angle

The nurse is caring for a client who had an exploratory laparotomy for a small bowel obstruction. Which assessment findings require follow-up by the nurse? (Select all that Apply) A. reports pain in right calf B. left leg is cooler than the right leg C. right lower extremity edema D. reports passing flatus E. abdominal incision approximated and healing

A. reports pain in right calf B. left leg is cooler than the right leg C. right lower extremity edema

A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy? A. scheduled eye surgery in one week B. a cerebrovascular bleed 10 years ago C. A diet that includes many green, leafy vegetables every day D. Three vaginal births, the most recent 18 months ago

A. scheduled eye surgery in one week

A 59-year-old female client had a left knee arthroplasty 2 days ago. While walking with her walker to the bathroom, the client reported feeling chest tightness and wanted to get back into bed. The nurse performs a focused assessment. The client's assessment findings are listed. Which client findings require immediate follow-up by the nurse? (Select all that Apply) A. sudden onset dyspnea B. respirations 28 breaths per minute C. apical pulse 102 beats per minute D. blood pressure 128/78 E. oxygen saturation is 88% on room air F. reports chest discomfort and tightness G. states she is worried about going home H. requests oral pain medication

A. sudden onset dyspnea B. respirations 28 breaths per minute C. apical pulse 102 beats per minute E. oxygen saturation is 88% on room air F. reports chest discomfort and tightness

Which client is at risk for the development of postrenal failure? A. the client diagnosed with renal calculi B. the client with congestive heart failure (CHF) C. the client who takes NSAIDS for arthritis pain D. the client with resolving glomerulonephritis

A. the client diagnosed with renal calculi

Which client situation would suggest that the cause of acute renal failure is a pre-renal condition? A. diabetes mellitus B. hypotension C. aminoglycosides D. benin prostatic hypertrophy

B. hypotension

Which statement by a client regarding hemodialysis indicates that teaching on the management of this condition has been effective? A. "I should take my respiratory rate every day" B. "I should record my intake and output and weight on a daily basis" C. "I should have my BUN and creatinine levels drawn daily" D. "I should eat more bananas and avocados"

B. "I should record my intake and output and weight on a daily basis"

To assist in establishing a nursing diagnosis of risk for volume excess related to kidney failure, which of these questions should a nurse ask a client who has chronic renal failure? A. "have you lost weight despite an increased appetitie?" B. "have you had any difficulty breathing at home?" C. "have you been unable to do your normal activity lately?"

B. "have you had any difficulty breathing at home?"

A client with chronic renal failure is on a low sodium diet and asks if salt substitute can be used. What is the nurse's best response? A. "substitutions should be used in moderation only" B. "salt substitutes contain potassium and should not be used" C. "it may be used after you've had dialysis today" D. "you may use it with any meal"

B. "salt substitutes contain potassium and should not be used"

The nurse has been assigned to care for these five clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that Apply A. a client with non-displaced left radius fracture admitted for same-day surgery B. a client who is on complete bed rest following spinal surgery C. a client receiving oral antibiotic therapy D. a client receiving norepinephrine via a subclavian central venous catheter line E. a 90-year old client admitted for pneumonia

B. a client who is on complete bed rest following spinal surgery D. a client receiving norepinephrine via a subclavian central venous catheter line E. a 90-year old client admitted for pneumonia

The values for serum hemoglobin and hematocrit for the adult client with chronic renal failure are as follows: 9.7 g/dL and 29. What is the most likely cause of this finding? A. epogen overproduction B. altered red blood cell production C. chronic GI bleed D. vitamin D malabsorption

B. altered red blood cell production

The nurse is evaluating the expected outcomes following thrombolytic therapy for a right leg deep vein thrombosis. Which findings confirm a positive outcome? (Select all that Apply) A. pedal pulse weak B. client denies pain C. right extremity pink D. equal size in right and left extremity E. no bleeding or bruising noted

B. client denies pain C. right extremity pink D. equal size in right and left extremity E. no bleeding or bruising noted

A nurse is caring for a 10 year old who has acute glomerulonephritis. Which of the following findings should the nurse report to the provider? A. serum BUN 10mg/dL B. serum creatinine 1.8mg/dL C. blood pressure 100/74 D. urine output 950 mL over 24 hr

B. serum creatinine 1.8mg/dL

Which statement by the client indicates effective teaching in relation to fluid status between hemodialysis treatments? A. "Will increase my amount of activity everyday" B. "take my apical pulse and respiratory rate daily" C. "Measure my intake and output and weigh everyday" D. "Monitor blood urea nitrogen and creatinine levels weekly"

C. "Measure my intake and output and weigh everyday"

Which clinical manifestation indicates that the client with glomerulonephritis responding as expected to the prescribed treatment? A. urine specific gravity is 1.048 B. client reports feeling thirsty C. 11 pound weight loss in 3 days D. no blood is observed in the client's urine

C. 11 pound weight loss in 3 days

What is an appropriate diet for a client diagnosed with acute renal failure? A. a high potassium and low calcium diet B. a low fat and low cholesterol diet C. a high carbohydrate and restricted protein diet D. a regular diet with six feedings a day

C. a high carbohydrate and restricted protein diet

The client with a history of chronic UTIs is reporting chills, fever and left costovertebral pain. Which diagnostic test would the nurse expect the healthcare provider to order? A. a sonogram of the kidney B. a CT scan of the kidneys C. a urine culture D. an intravenous pyelogram

C. a urine culture

Which interventions are appropriate to include in the plan of care for a patient admitted with a deep vein thrombosis (DVT)? Select all that Apply A. placing the client on strict bed rest B. teaching the patient to massage the affected extremity to reduce swelling C. administering unfractionated heparin D. maintaining the distal portion of the extremity lower than the proximal portion E. monitoring for sudden onset of shortness of breath

C. administering unfractionated heparin E. monitoring for sudden onset of shortness of breath

A nurse working as part of a diaster response team is triaging clients. Which of the following clients would the nurse color code as green? (Select all that Apply) A. client with a sucking chest wound B. client with multiple injuries in profound shock C. client with a first degree burn to the forearm D. unresponsive client with a penetrating head wound E. client with a broken arm

C. client with a first degree burn to the forearm E. client with a broken arm

A client with diabetes is diagnosed with chronic renal failure. The healthcare provider orders erythropoietin injections triweekly. Which of these statements by the client determines a need for additional education about the effect of erythropoietin? A. "Iron is necessary for erythropoietin to work well, therefore; i may need to take iron supplements B. "Erythropoietin is given to alleviate my symptoms of malaise and decreased activity tolerance" C. "I will experience flu-like symptoms during the initiation of therapy, which will subside with repeated doses" D. "Erythropoietin will help prevent infections and bleeding when it begins to have an effect in several weeks"

D. "Erythropoietin will help prevent infections and bleeding when it begins to have an effect in several weeks"

A nurse admits a client diagnosed with acute renal failure (ARF). Which question is appropriate for the nurse to ask on admission? A. "Have you recently traveled outside the United States?" B. "Did you recently begin a vigorous exercise program?" C. "Is there a chance you have been exposed to a virus?" D. "What over the counter medications do you take regularly?"

D. "What over the counter medications do you take regularly?"

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury? A. life-threatening but survivable with minimal intervention B. significant; injuries require medical care but can wait hours without threat to life or limb C. Extensive; chances of survival are unlikely even with definitive care D. Minor; treatment can be delayed hours to days

D. Minor; treatment can be delayed hours to days

A nurse is working at the scene of a catastrophic natural event. Which person should the nurse provide to care first? A. a 8 year old loudly with no movement in the lower extremities B. a confused client with a laceration to the forehead C. a client with no visible injuries and talks in gasps D. a client with a broken jaw that is unable to follow commands

D. a client with a broken jaw that is unable to follow commands

A nurse is working at the scene of a catastrophic natural event. Which person should the nurse provide care to first? A. an unresponsive client with a deformity to C-spine B. a client with a puncture wound to the eye C. a client with deformities to upper and lower extremities and responds to verbal commands D. a client with black discoloration around nose and mouth with audible wheezing

D. a client with black discoloration around nose and mouth with audible wheezing

A client diagnosed with end stage renal disease is not compliant with dietary restrictions. Which action should the nurse initiate FIRST? A. teach the client the proper diet to eat while on dialysis B. refer the client and signifiant other to the dietician C. explain the importance of eating the proper foods D. determine the reason for the client's noncompliance

D. determine the reason for the client's noncompliance

A healthcare provider orders intravenous sodium bicarbonate to be given to a client in acute renal failure whose serum potassium level is 6.3 mEQ/L. Which outcome should a nurse expect with the administration of sodium bicarbonate? A. increases the release of insulin, which promotes the movement of potassium into the cell B. promotes the loss of body potassium by the excretion of potassium in alkaline urine C. promotes the exchange of potassium ions for sodium ions into the renal tubules, which increases potassium elimination D. increases the blood pH, which results in the movement of potassium from the extracellular fluid into the cells.

D. increases the blood pH, which results in the movement of potassium from the extracellular fluid into the cells.

To reduce the incidence of peritoneal dialysis complications, which action should a nurse implement? A. monitor for hyperglycemia and osmotic diuresis post-dialysis B. promote a high protein diet to prevent negative nitrogen balance C. maintain the client in a upright position during dwell time D. maintain strict aseptic technique in tubing connections and catheter site care

D. maintain strict aseptic technique in tubing connections and catheter site care

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? a. Red b. Yellow c. Green d. Black

Red

Which of the following three components in the pathogenesis of clot formation make up Virchow's Triad? A. blood flow abnormalities, contact surface abnormalities, clotting component abnormalities B. blood flow abnormalities, long bone fractures, hypoxemia C. contact surface abnormalities, respiratory system abnormalities, integumentary disruption D. clotting component abnormalities, neurovascular component abnormalities, cardiovascular system abnormalities

blood flow abnormalities, contact surface abnormalities, clotting component abnormalities

Which finding in a client with a pulmonary embolus warrants immediate interventions by the nurse? A. diaphoresis B. S4 heart sounds C. blood pressure 80/56 D. syncope

blood pressure 80/56

Which nursing task would be most appropriate for the nurse to delegate to a nursing assistant on a medical floor? A. collect a clean voided midstream urine specimen B. evaluate the client's 8 hour intake and output C. assist in checking a unit of blood prior to hanging D. administer a kayexalate enema

collect a clean voided midstream urine specimen

A nurse is caring for a client with a deep vein thrombosis. Which change in assessment findings does the nurse find most concerning? A. nonproductive cough and abdominal pain B. hypertension and lack of fever C. bradypnea and bradycardia D. chest pain and dyspnea

chest pain and dyspnea

Post hemodialysis, a nurse notes the client's oral temperature is 100.2F. Which of the following is the appropriate nursing action? A. encourage oral fluids B. notify healthcare provider C. continue to monitor vital signs D. monitor shunt for infection

continue to monitor vital signs

While caring for a postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thrombosis, the nurse should contact the client's health care provider (HCP) immediately if the client exhibited which symptom? A. pain in her calf B. dyspnea C. bradycardia D. hypertension

dyspnea

What is an appropriate outcome for a client diagnosed with acute renal failure? A. monitor intake and output every shift B. decrease pain by 3 levels of a 1-10 scale C. electrolytes are within normal limits D. administer enemas to decrease hyperkalemia

electrolytes are within normal limits

Which nursing measure should receive immediate priority in the care for an anuric, fluid overload, hypertensive crisis client who has chronic renal failure? A. fluid restrictions B. diuretic therapy C. hemodialysis treatment D. epogen administration

hemodialysis treatment

What is a rare type of drug reaction that is complication of administration of unfractionated heparin? A. pulmonary embolism B. minor bleeding at the intravenous site C. osteopenia D. heparin induced thrombocytopenia

heparin induced thrombocytopenia

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include: oxygen 2-4 L/min per nasal cannula, oximetry at all times, IV administration of 5% dextrose in water at 100mL/hr. The client has increasing dyspnea and has a respiratory rate of 32 breaths/min. The oxygen flow rate is set at 2L/min. The nurse should first: A. provide reassurance to the client B. obtain a sample for arterial blood gas analysis C. call the healthcare provider (HCP) immediately. D. increase the oxygen flow rate from 2 to 4 L/min

increase the oxygen flow rate from 2 to 4 L/min

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? A. obtain intravenous (IV) access B. administer a heparin bolus and begin an infusion at 500 units/hr C. initiate oxygen therapy D. administer analgesics as ordered

initiate oxygen therapy

The telemetry monitor technician notifies the nurse of the monitoring telemetry readings. Which client should the nurse assess first? A. normal sinus rhythm with peaked T-waves B. atrial fibrillation with a rate of 100 C. coronary artery disease with occasional PVC's D. sinus bradycardia with a blood pressure of 120/60

normal sinus rhythm with peaked T-waves

A client with acute renal failure has a serum potassium level of 6.0 mEq/L. Which action by the nurse is a priority? A. check serum sodium level B. place the client on a cardiac monitor C. increase vegetables in diet D. allow 500 mL of fluid intake

place the client on a cardiac monitor

Following a myocardial infarction a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his healthcare provider. Which of the following choices reflects the purpose of exercise for this client? A. prevents bedsores B. prevents deep vein thrombosis (DVT) C. prevents future heart attacks D. prevents constipation

prevents deep vein thrombosis (DVT)

The client was involved in a motor vehicle accident and underwent operative repair of a femur fracture 1 day ago. There is a history of diabetes mellitus and alcohol abuse, and the client smokes two packs of cigarettes a day. A pulmonary embolism has developed, and had been started on heparin therapy. What should the nurse consider as a relative contraindication for heparin therapy? A. alcohol abuse B. diabetes mellitus C. smoking D. recent trauma

recent trauma

Which of the following findings in a client who recently underwent a total hip replacement would require a nurse to take immediate action? A. red painful area on the calf of the affected leg B. slight nontender edema in the nonaffected leg C. ecchymosis around the incision site D. three episodes of emesis in the last hour

red painful area on the calf of the affected leg

A client diagnosed with acute renal failure has hyperkalemia. Which medication should the nurse anticipate administering to help decrease the potassium level? A. eryhtropoietin B. calcium gluconate C. regular insulin D. osmotic diuretic

regular insulin

Which action should the nurse utilize to help prevent cardiovascular complications in a client with chronic renal disease? A. evaluate ankles for edema daily B. restrict sodium and fluid intake C. maintain a low-fat, low-cholesterol diet D. educate of the use of a salt substitute

restrict sodium and fluid intake

A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first? A. the client who had difficulty sleeping, daytime fatigue and morning headache B. the client with unilateral leg swelling who's complaining of anxiety and shortness of breath C. the client with crackles and fever who is complaining of pleuritic pain D. the client with anorexia, weight loss and night sweats

the client with unilateral leg swelling who's complaining of anxiety and shortness of breath

In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse should include which of the following in the plan of care? A. encourage deep breathing B. use pneumatic compression stockings C. limit fluids to 1000mL in 24 hours D. assist the client to remain sedentary

use pneumatic compression stockings