exam 4 A 229
A client with C8 tetraplegia is admitted to the emergency room. The client develops a blood pressure of 80/40 mm Hg, pulse 48 beats/min, and respiratory rate (RR) of 18 breaths/min. The nurse suspects which condition? Autonomic dysreflexia Hemorrhagic shock Neurogenic shock Pulmonary embolism
Neurogenic shock
While reviewing the laboratory results of a client in an acute care setting, the nurse finds urine output of 250 mL in 24 hours, blood osmolality of 310 milliosmoles per kg, and a systolic blood pressure of 90 mm Hg. What is the priority nursing intervention in this situation? Consider it as a normal finding. Advise the client to drink 2 to 3 L of water daily. Assess the creatinine and blood urea nitrogen (BUN) levels. Request an increase in the intravenous fluid rate from the healthcare provider.
Request an increase in the intravenous fluid rate from the healthcare provider.
A client has undergone pelvic surgery and the nurse removes the catheter in a week according to instructions. In the follow up within several hours, which finding in the client indicates a need for reinsertion of catheter? Anuria Polyuria Retention Incontinence
Retention
A client with acute kidney injury moves into the diuretic phase after 1 week of therapy. For which clinical indicators during this phase should the nurse assess the client? Select all that apply. Skin rash Correct! Dehydration Correct! Hypovolemia Hyperkalemia Metabolic acidosis
Dehydration Hypovolemia
The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response? Hemodynamic changes related to tilt table positioning Deteriorating myelin sheath Distended large intestine Crushed spinal cord
Distended large intestine
A client with end-stage renal disease is hospitalized. For which complications should the nurse monitor the client? Select all that apply. Anemia Dyspnea Jaundice Hyperexcitability Hypophosphatemia
Dyspnea Anemia
A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy? It provides continuous contact of dialyzer axind blood to clear toxins by ultrafiltration." It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine." It decreases the need for immobility, because it clears toxins in short and intermittent periods." It uses the peritoneum as a semipermeable membrane to clear tons by osmosis and diffusion."
It uses the peritoneum as a semipermeable membrane to clear tons by osmosis and diffusion."
Which laboratory finding is suggestive of mild kidney disease in male clients? Serum creatinine - 0.9 mg/dL Urinary albumin - 24 mg/mmol Blood urea nitrogen (BUN) - 18 mg/dL Blood urea nitrogen (BUN)/creatinine ratio - 23
Urinary albumin - 24 mg/mmol
The patient with peripheral facial paresis on the left side of her face is diagnosed with Bell's palsy. What should the nurse include in teaching the patient about self-care (select all that apply)? Administration of antiseizure medications Preparing for a nerve block to relieve pain Administration of corticosteroid medications Dark glasses and artificial tears to protect the eyes Surgeries available if conservative therapy is not effective
Administration of corticosteroid medications Dark glasses and artificial tears to protect the eyes
A client with acute kidney failure is fatigued and becomes lethargic. Upon reviewing the client's medical record, which finding does the nurse determine is the most likely cause of this change in symptoms? Hyperkalemia Hypernatremia A limited fluid intake An increased blood urea nitrogen level
An increased blood urea nitrogen level
A client has returned from spinal surgery. Which action is essential for the nurse to take? Encourage the client to drink fluids. Log-roll the client to the prone position. Assess the client's feet for circulation and sensation. Observe the client's bowel movements and voiding patterns.
Assess the client's feet for circulation and sensation.
Which nursing intervention is most appropriate for a client in skeletal traction? Add and remove weights as the client desires. Assess the pin sites at least every shift and as needed. Ensure that the knots in the rope are tied to the pulley. Perform range of motion to joints proximal and distal to the fracture at least once a day.
Assess the pin sites at least every shift and as needed.
A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase? Inhibiting urinary tract infections Preventing contractures and atrophy Avoiding flexion or hyperextension of the spine Preparing the client for vocational rehabilitation
Avoiding flexion or hyperextension of the spine
The nurse teaches a client who developed degenerative joint disease of the vertebral column positioning techniques, including turning from back to side, keeping the spine straight. The nurse explains that the least effort will be exerted if the client crosses the arm over the chest and does what? Uses the overbed table to pull the upper body up to assist with turning Bends the top knee to the side to which the client is turning Crosses the ankles while turning and keeps both legs straight Flexes the bottom knee to the side to which the client wishes to turn
Bends the top knee to the side to which the client is turning
A nurse is caring for a client with acute kidney injury. Which findings should the nurse anticipate when reviewing the laboratory report of the client's blood level of calcium, potassium, and creatinine? Select all that apply. Calcium: 7.6 mg/dL (1.9 mmol/L) Calcium: 10.5 mg/dL (2.6 mmol/L) Potassium 6.0 mEq/L (6.0 mmol/L) Potassium 3.5 mEq/L (3.5 mmol/L) Creatinine: 3.2 mg/dL (194 mcmol/L) Creatinine: 1.1 mg/dL (90 mcmol/L)
Calcium: 7.6 mg/dL (1.9 mmol/L) Potassium 6.0 mEq/L (6.0 mmol/L) Creatinine: 3.2 mg/dL (194 mcmol/L)
A client develops kidney damage as a result of a transfusion reaction. What is the most significant clinical response that the nurse will assess when determining kidney damage? Glycosuria Blood in the urine Decreased urinary output Acute pain over the kidney
Decreased urinary output
A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority during rehabilitation? Prevent urinary tract infections. Monitor the patient every 15 minutes. Encourage him to verbalize his feelings. Teach him about using the gastrocolic reflex.
Encourage him to verbalize his feelings.
A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. Spasticity Incontinence Flaccid paralysis Respiratory failure Lack of reflexes below the injury
Flaccid paralysis Lack of reflexes below the injury
A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. Spasticity Incontinence Flaccid paralysis Respiratory failure Lack of reflexes below the injury
Flaccid paralysis Lack of reflexes below the injury
A nurse anticipates that dialysis will be necessary for a client with chronic kidney disease when the client begins to exhibit which symptom? Hypotension Hypokalemia Hypervolemia Hypercalcemia
Hypervolemia
The nurse is teaching self-management techniques to a client newly diagnosed with polycystic kidney disease. Which statement of the client indicates a need for further teaching? I should monitor my bowel movements." I should weigh myself once a week." I should record my blood pressure daily." "I should notify my healthcare provider if I have fever."
I should weigh myself once a week."
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority? Risk for impairment of tissue integrity caused by paralysis Altered patterns of urinary elimination caused by tetraplegia Altered family and individual coping caused by the extent of trauma Ineffective airway clearance caused by high cervical spinal cord injury
Ineffective airway clearance caused by high cervical spinal cord injury
A client was admitted to the hospital with a direct injury to the vertebral column from a gunshot after a mass shooting. The nurse suspects a spinal cord injury. Which mechanism of injury might be the reason for the injury? Hyperflexion Hyperextension Excessive rotation Penetrating trauma
Penetrating trauma
A client who was in a traffic accident is choking. The nurse suspects that the client may have a spinal cord injury. Which procedure may benefit the client? Performing vagal maneuver Performing Valsalva maneuver Performing jaw-thrust maneuver Performing oculocephalic maneuver
Performing jaw-thrust maneuver
A client with chronic kidney disease is receiving medication to manage anemia. Which primary goal should the nurse include in the care plan from this information? Prevention of uremic frost Prevention of chronic fatigue Prevention of tubular necrosis Prevention of dependent edema
Prevention of chronic fatigue
A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)? Fluid Protein Sodium Potassium
Protein
The nurse assesses for damage to the glossopharyngeal (ninth cranial) and vagus (tenth cranial) nerves. Which action will the nurse ask the client to perform? Shrug Smell Smile Swallow
Swallow
To prepare for hemodialysis, a client with end-stage kidney disease is scheduled for surgery, specifically for the creation of an internal arteriovenous fistula in one arm and placement of an external arteriovenous shunt in the other arm. When considering care for these sites, which difference will the nurse consider? Blood pressure readings can be taken in the arm with the fistula but not the one with the shunt. Intravenous (IV) fluids can be administered in the arm with the shunt but not the one with the fistula. The fistula should be covered with a light dressing, and the shunt should be covered thoroughly with a heavy dressing. The graft is more subject to hemorrhage, clotting, and infection than the fistula is.
The graft is more subject to hemorrhage, clotting, and infection than the fistula is.
The registered nurse is instructing the student nurse regarding the gross anatomy and physiology of the kidneys prior to client examination. Which statement made by the student nurse indicates the nurse needs to intervene? The right kidney is a little longer and narrower than the left kidney." The existence of three kidneys with normal kidney function is normal." The presence of a single kidney with normal kidney function is normal." The urinary bladder lies directly behind the pubic bone."
The right kidney is a little longer and narrower than the left kidney."
After reviewing the 24-hour urine collection reports of a client with kidney dysfunction, the nurse suspects diabetes mellitus. Which finding supports this suspicion? Calcium level: 500 mg/24 hr Sodium level: 300 mEq/24 hr Urea nitrogen level: 30 g/24 hr Creatinine level: 40 mg/kg/24 hr
Creatinine level: 40 mg/kg/24 hr
Which instructions will be most beneficial for a diabetic client with renal disease? Select all that apply. Recommend the client drink boiled water Suggest the client to go for a morning walk Instruct the client to check blood pressure regularly Contact the primary healthcare provider before taking ibuprofen Encourage the client to undergo a microalbuminuria test yearly
Correct! Instruct the client to check blood pressure regularly Correct! Contact the primary healthcare provider before taking ibuprofen Correct Answer Encourage the client to undergo a microalbuminuria test yearly
A registered nurse is providing information to a group of student nurses regarding the actions of parathyroid hormone (PTH). Which statement made by the student nurse indicates a need for further teaching? Select all that apply. It activates vitamin D in the kidneys." Its secretion increases serum calcium levels." It allows reabsorption of phosphorus in the kidney tubules." It decreases serum calcium levels by increasing bone resorption." It regulates calcium and phosphorous metabolism by acting on the gastrointestinal tract."
Correct! It allows reabsorption of phosphorus in the kidney tubules." Correct Answer It decreases serum calcium levels by increasing bone resorption."
A nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client's questions? A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses. Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys. Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein.
This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.
A client who is diagnosed as having a herniated nucleus pulposus reports pain. What should the nurse most likely conclude is the cause of this client's pain? Inflammation of the lamina of the involved vertebra Shifting of two adjacent vertebral bodies out of alignment Compression of the spinal cord by the extruded nucleus pulposus Increased pressure of cerebrospinal fluid within the vertebral column
Compression of the spinal cord by the extruded nucleus pulposus
Following a traumatic spinal cord severance, a client experiences severe leg spasms and asks the nurse what is causing them. How should the nurse respond? "Spinal shock has subsided, and your reflexes are hyperactive." You have developed thrombophlebitis, which is causing your pain." The nerves are regenerating, and your motor function is returning." Motor function may be returning now that your edema is subsiding."
"Spinal shock has subsided, and your reflexes are hyperactive."
A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? Wear sterile gloves when doing the procedure." Wash your hands before performing the procedure." Perform the self-catheterization every 12 hours." Dispose of the catheter after you have catheterized yourself."
Wash your hands before performing the procedure."
A client is to have hemodialysis. What must the nurse do before this treatment? Obtain a urine specimen to evaluate kidney function. Weigh the client to establish a baseline for later comparison. Administer medications that are scheduled to be given within the next hour. Explain that the peritoneum serves as a semipermeable membrane to remove wastes.
Weigh the client to establish a baseline for later comparison.
While assessing a client recovering from a head injury, the nurse notices a loss of movement in the client's tongue while attempting to talk. Which could be the possible reason for the client's condition? Damage to the facial nerve Damage to the trigeminal nerve Damage to the hypoglossal nerve Damage to the glossopharyngeal nerve
Damage to the hypoglossal nerve
A client who has paraplegia often loses calcium from the skeletal system. The nurse concludes that what factor contributes to calcium loss in this client? Decreased activity Inadequate fluid intake Decreased calcium intake Inadequate kidney function
Decreased activity
A nurse is caring for a client with end-stage kidney disease after a kidney transplant. Which finding indicates the transplant is successful? Increased specific gravity Correction of hypotension Elevated serum potassium Decreasing serum creatinine
Decreasing serum creatinine
A nurse in the emergency department is caring for a client with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action? Placing the client's head on a pillow for support Correct! Immobilizing the client's spine to limit additional injury Log-rolling the client to check for lacerations on the back Moving the client onto a firm stretcher for transport to the radiography department
Immobilizing the client's spine to limit additional injury
While reviewing the urinalysis reports of an elderly client, the nurse finds white blood cells (WBCs) in the urine. Which condition might the client have? Pyelonephritis Kidney trauma Kidney infection Acute tubular necrosis
Kidney infection
A client is hospitalized with head trauma. Which imaging test should the nurse anticipate being prescribed by the primary healthcare provider to rule out a cervical spine fracture? Plain x-ray Cerebral angiography Computed tomography (CT) Positron emission tomography (PET)
Plain x-ray
An older adult client is admitted to the hospital with a diagnosis of chronic kidney disease. The nurse reviews the client's medical record. Which clinical finding is a priority to be communicated to the primary healthcare provider? Sodium level Potassium level Creatinine clearance Blood pressure
Potassium level
Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action? Change the client's diet to bland. Obtain a stool specimen for occult blood. Prepare for insertion of a nasogastric tube. Monitor recent laboratory reports for hemoglobin levels.
Prepare for insertion of a nasogastric tube.
A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)? Fluid Protein Sodium Potassium
Protein
Which diagnostic tests are used to measure the kidney size of a client with kidney dysfunction? Select all that apply. Cystoscopy Cystography Radiography Cystourethrography Computed tomography (CT)
Radiography Computed tomography (CT)
What are the reasons for performing a lumbar puncture on a client? Select all that apply. Confirming spinal cord injuries Assessing sensory nerve problems Measuring blood flow in many areas Reading cerebrospinal fluid pressure Injecting contrast medium for diagnostic study
Reading cerebrospinal fluid pressure Injecting contrast medium for diagnostic study
Client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction? Relieving muscle spasm and pain Preventing contractures from developing Keeping the client from turning and moving in bed Maintaining the limb in a position of external rotation
Relieving muscle spasm and pain
A client who has been on hemodialysis for several weeks asks the nurse what substances are being removed by the dialysis. Which substance removal should the nurse share with the client? Blood Sodium Glucose Bacteria
Sodium
A client sustains a back injury after falling 20 feet (6 m). In which position should the nurse place the client? Lateral position with a pillow between the knees Any position that reduces pain and is comfortable Supine position while not allowing the spine to flex Sitting position with a pillow placed in the small of the back
Supine position while not allowing the spine to flex
A client with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The nurse should monitor the client for which peritoneal dialysis complications? Select all that apply. Pruritus Oliguria Tachycardia Cloudy outflow Abdominal pain
Tachycardia Cloudy outflow Abdominal pain
The nurse is caring for a client one week after the client experienced a spinal cord injury at the T3 level. What is an appropriate short-term goal for this client? The client will understand limitations." The client will consider lifestyle changes." The client will perform independent ambulation." The client will carry out personal hygiene activities."
The client will carry out personal hygiene activities."
A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? Arrangements will be made by the client and the client's family. The plan is formulated and implemented early in the client's care. The rehabilitation is minimal and short term, because the client will return to former activities. Arrangements will be made for long-term care, because the client is no longer capable of self-car
The plan is formulated and implemented early in the client's care.
A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Why is this necessary? Reflexes have been lost. There is partial transection of the cord. There is damage above the sixth thoracic vertebra. Flaccid paralysis of the lower extremities has occurred.
There is damage above the sixth thoracic vertebra.
The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? You Answered Dehydration Skin breakdown Electrolyte imbalances Urinary tract infections
Urinary tract infections
After learning about rehabilitation for his spinal cord tumor, which statement shows the patient understands what rehabilitation is and can do for him? "I want to be rehabilitated for my daughter's wedding in 2 weeks." "Rehabilitation will be more work done by me alone to try to get better." "I will be able to do all my normal activities after I go through rehabilitation." "With rehabilitation, I will be able to function at my highest level of wellness."
"With rehabilitation, I will be able to function at my highest level of wellness."
A client with acute kidney failure is fatigued and becomes lethargic. Upon reviewing the client's medical record, which finding does the nurse determine is the most likely cause of this change in symptoms? Hyperkalemia Hypernatremia A limited fluid intake An increased blood urea nitrogen level
An increased blood urea nitrogen level
A 68-year-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl (Dulcolax) suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist the patient with bowel evacuation (select all that apply)? Drink more milk Eat 20-30 g of fiber per day. Use oral laxatives every day. Drink 1800 to 2800 mL of water or juice. Establish bowel evacuation time at bedtime.
Eat 20-30 g of fiber per day. Drink 1800 to 2800 mL of water or juice.
A client with a history of chronic kidney disease is hospitalized. Which assessment findings will alert the nurse to kidney insufficiency? Facial flushing Edema and pruritus Dribbling after voiding and dysuria Diminished force and caliber of stream
Edema and pruritus
The nurse is caring for a client who just had a posterior lumbar laminectomy. Which action is the priority? Encourage the client to cough. Reposition the client by log rolling. Assess the client for indications of peritonitis. Instruct the client to bend the knees when turning.
Reposition the client by log rolling.
The nurse is caring for a client immediately after a subtotal thyroidectomy. How will the nurse assess for unilateral injury of the laryngeal nerve? Checking the throat for edema Asking the client to say what the current time is Eliciting spasms of the facial muscles Palpating the neck for seepage of blood
Asking the client to say what the current time is
A client with acute kidney injury states, "Why am I twitching and my fingers and toes tingling?" Which process should the nurse consider when formulating a response to this client? Acidosis Calcium depletion Potassium retention Sodium chloride depletion
Calcium depletion
A client has surgery for the creation of burr holes after sustaining head trauma. Which early clinical manifestation of meningeal irritation does the nurse assess in the client? Sunset eyes Kernig sign Plantar reflex Homans sign
Kernig sign
A client has end-stage kidney disease and is admitted for a kidney transplant. Which information should the nurse share when teaching about the donor? Must have the same blood type Must be a member of the same family Must be approximately the same body size Must have matching leukocyte antigen complexes
Must have matching leukocyte antigen complexes
A client has a discectomy and fusion for a herniated disc. When getting out of bed for the first time, the client reports feeling faint and lightheaded. Which instruction should the nurse provide to the client? "Sit upright on edge of the bed." Slide to the floor to prevent a fall and injury." Bend forward to increase the blood flow to the brain." Lie down immediately so a blood pressure can be obtained."
Sit upright on edge of the bed."
A client has a discectomy and fusion for a herniated nucleus pulposus (HNP). When getting out of bed for the first time, the client reports feeling faint and lightheaded. Which instruction should the nurse provide to the client? Sit upright on edge of the bed." Slide to the floor to prevent a fall and injury." Bend forward to increase the blood flow to the brain." Lie down immediately so a blood pressure can be obtained."
Sit upright on edge of the bed."
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? Central cord syndrome Spinal shock syndrome Anterior cord syndrome Brown-Séquard syndrome
Spinal shock syndrome
The patient is brought to the emergency department after a car accident and has a femur fracture. What nursing intervention should the nurse implement to prevent a fat embolus in this patient? Administer enoxaparin (Lovenox). Provide range-of-motion exercises. Apply sequential compression boots. Immobilize the fracture preoperatively.
Immobilize the fracture preoperatively.
The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period? Bladder control Nutritional intake Quadriceps setting Use of aids for ambulation
Bladder control
The laboratory report of a client indicates that the urinary urea nitrogen levels are 9 g/24 hr. What does the nurse anticipate from this finding? Client has sepsis Client has dehydration Client has high-protein intake Client has potential kidney damage
Client has potential kidney damage
A nurse is evaluating sensory changes in a client whose spinal cord was severed at the level of T6 and T7. What does this evaluation process require? Client squeezing the nurse's hand Nurse monitoring the client's vital signs Client stating where the pinching sensation is felt Nurse observing the skin for color changes below the lesion
Client stating where the pinching sensation is felt
A client with a history of chronic kidney disease is hospitalized. Which assessment findings will alert the nurse to kidney insufficiency? Facial flushing Edema and pruritus Dribbling after voiding and dysuria Diminished force and caliber of stream
Edema and pruritus
A nurse is caring for a 10-year-old boy who sustained a fractured cervical vertebra while playing football. When he is placed in cervical traction, what does the nurse teach him that the traction will achieve? Flex the head to prevent stretching of the neck muscles Immobilize the area to minimize injury to the spinal cord Align the body to allow for cerebrospinal fluid to encircle the spinal cord Hyperextend the neck to maintain an open airway
Immobilize the area to minimize injury to the spinal cord
Which organ-specific autoimmune disorder is associated with a client's kidney? Graves' disease Addison's disease Goodpasture syndrome Guillain-Barré syndrome
Goodpasture syndrome
A client is admitted to the hospital after falling and fracturing a hip. The primary healthcare provider applies a Buck boot with traction until surgery to replace the head of the femur with a prosthesis can be performed. What action can the nurse take to ensure that the Buck traction is being applied correctly? Fit the spreader bar snugly around the foot. Position the boot so it extends 3 inches (7.6 cm) above the ankle. Hang the weight to apply traction, but limit it to 10 lb (4.5 kg). Cover the malleoli with tape to adequately secure the weights to the leg.
Hang the weight to apply traction, but limit it to 10 lb (4.5 kg).
A nurse is caring for a client receiving hemodialysis for chronic kidney disease. The nurse should monitor the client for which complication? Peritonitis Hepatitis B Renal calculi Bladder infection
Hepatitis B
A nurse is caring for a client receiving hemodialysis for chronic kidney disease. The nurse should monitor the client for which complication? You Answered Peritonitis Hepatitis B Renal calculi Bladder infection
Hepatitis B
A client is diagnosed as having kidney failure. During the oliguric phase, what should the nurse assess for in this client? Hypothermia Hyperphosphatemia Hypocalcemia Hypernatremia
Hyperphosphatemia
A nurse anticipates that dialysis will be necessary for a client with chronic kidney disease when the client begins to exhibit which symptom? Hypotension Hypokalemia Correct! Hypervolemia Hypercalcemia
Hypervolemia
A client with acute kidney injury is to receive peritoneal dialysis and asks why the procedure is necessary. Which is the nurse's best response? "It prevents the development of serious heart problems." It helps perform some of the work usually done by the kidneys." "It will keep your kidneys from getting worse and may 'restart' your kidneys to perform better than before." It speeds recovery because the kidneys are not responding to regulating hormones."
It helps perform some of the work usually done by the kidneys."
The nurse is caring for a client who is admitted with a crushing injury to the spinal cord above the level of phrenic nerve origin. What should the nurse consider about this type of injury when planning care? Ventricular fibrillation Vagus nerve dysfunction Retention of sensation and paralysis of lower extremities Lack of diaphragmatic contractions and respiratory paralysis
Lack of diaphragmatic contractions and respiratory paralysis
A client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client is depressed and irritable. The client's spouse asks the nurse about the anticipated plan of care. Which is an appropriate nursing response? The staff will provide total care, because the infection causes severe fatigue." "Mood elevators will be prescribed to improve depression and irritability." Vitamin B<sub>12</sub> will be prescribed for the anemia, and the stools will be dark." Correct! The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products."
The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products."
The registered nurse discusses normal renal function with the client. Which statements made by the client are correct regarding regulatory functions of the kidney? Select all that apply. They play a role in erythropoiesis." They play a role in acid-base balance." They play a role in vitamin D activation." They play a role in blood pressure regulation." They play a role in fluid and electrolyte balance."
They play a role in acid-base balance." They play a role in fluid and electrolyte balance."
A client is to have hemodialysis. What must the nurse do before this treatment? Obtain a urine specimen to evaluate kidney function. Weigh the client to establish a baseline for later comparison. Administer medications that are scheduled to be given within the next hour. Explain that the peritoneum serves as a semipermeable membrane to remove wastes.
Weigh the client to establish a baseline for later comparison.
A client is diagnosed with acute kidney failure secondary to dehydration. An intravenous (IV) infusion of 50% glucose with regular insulin is prescribed. What does the nurse recognize as the primary purpose of the IV insulin for this client? hyperkalemia Increase urinary output Prevent respiratory acidosis Increase serum calcium levels
hyperkalemia
The nurse is completing discharge teaching with an 80-year-old male patient who underwent right total hip arthroplasty. The nurse identifies a need for further instruction if the patient states the need to avoid crossing his legs. use a toilet elevator on toilet seat. notify future caregivers about the prosthesis. maintain hip in adduction and internal rotation.
maintain hip in adduction and internal rotation.