Medsurg 2 Final Exam (New Topics)

Metabolic acidosis occurs in the oliguric phase of AKI as a result of impairment of a. ammonia synthesis. b. excretion of sodium. c. excretion of bicarbonate. d. conservation of potassium.

a

Which clinical indicators would the nurse expect for a client who has end-stage renal disease (ESRD)? Select all that apply. a) polyuria b) jaundice c) azotemia d) hypertension e) polycythemia

c and d

Which instruction would be included in a discharge plan for a client hospitalized with severe cirrhosis of the liver? a) the need for a high-protein diet to avoid malnourishment b) the use of a sedative for relaxation to decrease personal stress c) the need to increase daily intake of oral fluids d) the need to report personality changes to the primary health care provider

d

Priority Decision: A patient on a medical unit has a potassium level of 6.8 mEq/L. What is the priority action that the nurse should take? a. Place the patient on a cardiac monitor. b. Check the patient's blood pressure (BP). c. Instruct the patient to avoid high-potassium foods. d. Call the lab and request a redraw of the lab to verify results.

a

Which example is associated with third spacing in a burn injury? a) blister formation b) edema formation c) fluid mobilization d) fluid accumulation

a

Which glasgow coma scale score would the nurse give a client who does not open the eyes to any stimulus, only makes incomprehensible sounds and moans, and extends the arm at the elbow with adduction and internal rotation of the arm at the shoulder? a) 5 b) 6 c) 7 d) 8

a

Which intervention would the nurse perform first for a client admitted with a closed head injury and increased intracranial pressure (ICP)? a) place the head and neck in neutral alignment b) obtain a prescription for 100mg of pentobarbital IV c) administer 1g mannitol intravenously (IV) as prescribed d) increase the ventilator's respiratory rate to 20 breaths/minute

a

Which assessment finding indicates that a client has had a stroke? select all that apply. a) lopsided smile b) unilateral vision c) incoherent speech d) unable to raise right arm e) symptoms started 2 hours ago

a,b,c,d,e

A client with a history of chronic kidney disease is hospitalized. which assessment findings would alert the nurse to suspect kidney insufficiency? a) facial flushing b) edema and pruritis c) dribbling after voiding d) diminished force of urination

b

Priority Decision: A dehydrated patient is in the Injury stage of the RIFLE staging of AKI. What would the nurse first anticipate in the treatment of this patient? a. Assess daily weight b. IV administration of fluid and furosemide (Lasix) c. IV administration of insulin and sodium bicarbonate d. Urinalysis to check for sediment, osmolality, sodium, and specific gravity

b

The nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information would the nurse include in the teaching session? Select all that apply. a) adhering to a low-car diet b) avoiding aspirin and aspirin-containing products c) limiting alcohol consumption to two drinks weekly d) avoiding acetaminophen and products containing acetaminophen e) avoiding coughing, sneezing, and straining to have a bowel movement

b,d,e

Which behaviors would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? Select all that apply. a) impaired judgement b) spatial-perceptual deficits c) slow performance and caution d) impaired speech/language aphasias e) tendency to deny or minimize problems f) awareness of deficits with depression and anxiety

c,d,f

Acute tubular necrosis (ATN) is the most common cause of intrarenal AKI. Which patient is most likely to develop ATN? a. Patient with diabetes mellitus b. Patient with hypertensive crisis c. Patient who tried to overdose on acetaminophen d. Patient with major surgery who required a blood transfusion

d

Which serum laboratory value indicates to the nurse that the patient's CKD is getting worse? a. Decreased BUN b. Decreased sodium c. Decreased creatinine d. Decreased calculated glomerular filtration rate (GFR)

d

How would the nurse classify burns that are painful, red to white, and edematous? a) escharr b) deep full thickness burn c) deep partial thickness burn d) superficial partial thickness burns

c

What accurately describes the care of the patient with CKD? a. A nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable is iron. b. The syndrome that includes all of the signs and symptoms seen in the various body systems in CKD is azotemia. c. The use of morphine is contraindicated in the patient with CKD because accumulation of its metabolites maycause seizures. d. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calciumlevels are increased.

d

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is an appropriate choice for a client with this disorder? a) Ham sandwich with cheese, whole milk, and potato chips b) Penne pasta, spinach, banana, and decaffeinated iced tea c) Baked lasagna with sausage, salad, and a milkshake d) Hamburger, french fries, and cola

b

What is the primary way that a nurse will evaluate the patency of an AVF? a. Palpate for pulses distal to the graft site. b. Auscultate for the presence of a bruit at the site. c. Evaluate the color and temperature of the extremity. d. Assess for the presence of numbness and tingling distal to the site.

b

Which rationale explains why the nurse would ask the client to void before a paracentesis? a) a full bladder decreases the intraabdominal pressure b) a full bladder decreases the amount of fluid in the abdominal cavity c) a full bladder increases the danger of puncture during the procedure d) a full bladder increases the presence of urea in the intraabdominal fluid

c

An 83-year-old female patient was found lying on the bathroom floor. She said she fell 2 days ago and has not beenable to take her heart medicine or eat or drink anything since then. What conditions could be causing prerenal AKI inthis patient (select all that apply)?a. Anaphylaxis b. Renal calculi c. Hypovolemia d. Nephrotoxic drugs e. Decreased cardiac output

c,e

What indicates to the nurse that a patient with oliguria has prerenal oliguria? a. Urine testing reveals a low specific gravity. b. Causative factor is malignant hypertension. c. Urine testing reveals a high sodium concentration. d. Reversal of oliguria occurs with fluid replacement.

d

Which assessment is necessary for the nurse to complete in a client with chronic kidney disease receiving loop diuretics? a) hemoglobin levels b) occurrence of nausea c) presence of constipation d) intake and output measurement

d

which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. a) wearing a medical alert bracelet b) initiating bleeding precautions c) refraining from estrogen therapy d) obtaining routine prothrombin times e) notifying providers of anticoagulation

a,b,c,d,e

During the oliguric phase of acute kidney injury, for which abnormal finding would the nurse monitor in the client? a) hypothermia b) hyperphosphatemia c) hypocalcemia d) hypernatremia

b

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick, coffee-ground material and appears restless and apprehensive. Which is the most important initial nursing action? a) change the clients diet to bland b) obtain a stool specimen for occult blood c) prepare for insertion of a nasogastric tube d) monitor recent lab reports for hemoglobin levels

c

What are intrarenal causes of acute kidney injury (AKI) (select all that apply)? a. Anaphylaxis b. Renal stones c. Bladder cancer d. Nephrotoxic drugs e. Acute glomerulonephritis f. Tubular obstruction by myoglobin

d,e,f

When providing care for a client with paraplegia secondary to a spinal cord injury, which potential complication may occur early during the recovery period? a) bladder control b) nutritional intake c) quadriceps setting d) use of aids for ambulation

a

A paracentesis is prescribed for a client recently admitted to a medical unit. The nurse recalls that the procedure is performed for what reasons? (Select all that apply.) a) Extract peritoneal fluid b) Improve respiratory status c) Decrease intrapleural fluid d) Increase intraabdominal tension e) Obtain peritoneal fluid for culture

a,b,e

In a patient with AKI, which laboratory urinalysis result indicates tubular damage? a. Hematuria b. Specific gravity fixed at 1.010 c. Urine sodium of 12 mEq/L (12 mmol/L) d. Osmolality of 1000 mOsm/kg (1000 mmol/kg)

b

Which assessment finding reflects increased intracranial pressure (ICP)? a) tachycardia b) unequal pupil size c) decreasing body temperature d) decreasing systolic blood pressure

b

Which finding for a client who has a diagnosis of paroxysmal atrial fibrillation is most important to report quickly to the health care provider? a) irregular heartbeat b) right arm weakness c) client report of palpitations d) client report of lightheadedness

b

A patient with AKI is a candidate for continuous renal replacement therapy (CRRT). What is the most commonindication for use of CRRT? a. Azotemia b. Pericarditis c. Fluid overload d. Hyperkalemia

c

The diagnostic reports of a client who underwent a hypophysectomy indicate an intracranial pressure (ICP) of 20mm Hg. Which action made by the client is responsible for the reported ICP? a) drinking lots of water b) eating high fiber foods c) bending over at the waist d) bending knees when lowering body

c

While caring for the patient in the oliguric phase of AKI, the nurse monitors the patient for associated collaborative problems. When should the nurse notify the health care provider? a. Urine output is 300 mL/day. b. Edema occurs in the feet, legs, and sacral area. c. Cardiac monitor reveals a depressed T wave and elevated ST segment. d. The patient experiences increasing muscle weakness and abdominal cramping.

d

The nurse is assessing a client 12 hours after the client sustained a deep partial thickness burn on the forearm. Which characteristics would the nurse expect to identify when assessing the injured tissue? a) painful and reddish white b) pinkish and tender c) charred and white d) leathery and black

a

What indicates to the nurse that a patient with AKI is in the recovery phase? a. A return to normal weight b. A urine output of 3700 mL/day c. Decreasing sodium and potassium levels d. Decreasing blood urea nitrogen (BUN) and creatinine levels

d

a client is admitted to the hospital with severe burns. Which clinical finding would the nurse anticipate during the acute phase of burn recovery? a) unstable vital signs b) decreased urinary output c) high serum potassium levels d) reduced intravascular fluid volume

a

A client with a history of excessive alcohol use develops hepatic portal hypertension and an elevated serum aldosterone level. For which complications would the nurse assess this client? a) chloride depletion and hypovolemia b) potassium retention and dysrhythmia c) sodium retention and fluid accumulation d) calcium depletion and pathological fractures

c

The patient with CKD is brought to the emergency department with Kussmaul respirations. What does the nurseknow about CKD that could cause this patient's Kussmaul respirations? a. Uremic pleuritis is occurring. b. There is decreased pulmonary macrophage activity. c. They are caused by respiratory compensation for metabolic acidosis. d. Pulmonary edema from heart failure and fluid overload is occurring.

c

A man with end-stage kidney disease is scheduled for hemodialysis following healing of an arteriovenous fistula(AVF). What should the nurse explain to him that will occur during dialysis? a. He will be able to visit, read, sleep, or watch TV while reclining in a chair. b. He will be placed on a cardiac monitor to detect any adverse effects that might occur c. The dialyzer will remove and hold part of his blood for 20 to 30 minutes to remove the waste products. d. A large catheter with two lumens will be inserted into the fistula to send blood to and return it from the dialyzer.

a

The nurse estimates that a client admitted in the oliguric phase of acute kidney injury had a urinary output of 200mL over the past 12 hours. The client's plan of care indicates a fluid restriction of 900mL of free water per 24 hours. Which interpretation of the amount of prescribed fluid would the nurse make? a) the fluid equals the expected urinary output for the next 24 hours b) the fluid prevents the development of pneumonia and a high fever c) the fluid compensates for insensible fluid loss and the expected urinary output d) The fluid reduced hyperkalemia, which can lead to life threatening cardiac dysrhythmias

c

Which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? a) place objects within the visual field b) teach passive range of motion exercises c) instill artificial teardrops into the affected eye d) reduce time client is positioned on the left side

a

Prevention of AKI is important because of the high mortality rate. Which patients are at increased risk for AKI(select all that apply)? a. An 86-year-old woman scheduled for a cardiac catheterization b. A 48-year-old man with multiple injuries from a motor vehicle accident c. A 32-year-old woman following a C-section delivery for abruptio placentae d. A 64-year-old woman with chronic heart failure admitted with bloody stools e. A 58-year-old man with prostate cancer undergoing preoperative workup for prostatectomy

a,b,c,d,e

Which aspects would the nurse assess to determine increasing intracranial pressure around the medulla? Select all that apply. a) taste b) breathing c) heart rate d) fluid balance e) voluntary movement

b and c

The nurse, caring for a client with full thickness burns of the anterior trunk and thigh, is monitoring fluid balance during the first 2 to 3 days after the burn. Which area is most important for the nurse to assess for fluid balance in this client? a) weight every day b) urinary output every hour c) blood pressure every 15 minutes d) extent of peripheral edema every 4 hours

b

Priority Decision: During the immediate postoperative care of a recipient of a kidney transplant, what should thenurse expect to do? a. Regulate fluid intake hourly based on urine output. b. Monitor urine-tinged drainage on abdominal dressing. c. Medicate the patient frequently for incisional flank pain. d. Remove the urinary catheter to evaluate the ureteral implant

a

The nurse is caring for a client with cirrhosis of the liver. The nurse anticipates a prescription for neomycin enemas based on which abnormal laboratory test? a) ammonia level b) culture and sensitivity c) white blood cell count d) alanine aminotransferase (ALT) level

a

A client has a diagnosis of patrial thickness burns. While planning care, the nurse recalls that the client's burn is different than full thickness burns. Which information did the nurse recall? a) partial thickness burns require grafting before they can heal b) partial thickness burns are often painful, reddened, and have blisters c) partial thickness burns cause destruction of both the epidermis and dermis d) partial thickness burns often take months of extensive treatment before healing

b

Which action would the nurse take to assess for ascites? a) observe the client for signs of respiratory distress b) percuss the client's abdomen and listen for dull sounds c) palpate the lower extremities over the tibia and observe for pitting d) auscultate for the absence of bowel sounds in the abdomen

b

The nurse is caring for a client who is admitted with a crushing injury to the spinal cord at the level of phrenic nerve origin. Which complication would the nurse anticipate when planning care? a) prolonged coma b) ventricular fibrillation c) diaphragmatic paralysis d) vagus nerve dysfunction

c

Which information would the nurse include in response to a client questioning a protein restricted dietary change required for his or her acute kidney injury? a) a high protein intake ensures an adequate daily supply of amino acids to compensate for losses b) Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis c) this diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys d) currently, your body id unable to synthesize amino acids, so the nitrogen for amino acid synthesis must come from the dietary protein

c

In caring for the patient with AKI, what should the nurse be aware of? a. The most common cause of death in AKI is irreversible metabolic acidosis. b. During the oliguric phase of AKI, daily fluid intake is limited to 1000 mL plus the prior day's measured fluid loss. c. Dietary sodium and potassium during the oliguric phase of AKI are managed according to the patient's urinary output. d. One of the most important nursing measures in managing fluid balance in the patient with AKI is taking accurate daily weights.

d

The nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in the client's diet? Select all that apply. a) high fat b) low sodium c) high vitamins d) moderate protein e) low carbohydrates

b,c,d

A client has a mean arterial blood pressure (MAP) of 97 mm Hg and an intracranial pressure (ICP) of 12 mm Hg. Calculate the cerebral perfusion pressure (CPP) for this client. Record your answer using a whole number.

85mm Hg. The CPP can be calculated by the following equation: CPP=MAP-ICP. If the MAP is 97 mm Hg and ICP is 12 mm Hg, the CPP is 85 mm Hg.

The nurse is caring for a client that is scheduled to have a percutaneous liver biopsy. Which assessment findings warrant the postponement of the procedure? Select all that apply. a) hemosiderosis b) marked ascites c) hepatic cirrhosis d) hemoglobin of less that 9 g/dL (90mmol/L) e) platelet count of 150,000mm3 (150x10^9/L)

b,d

A client with severe cirrhosis is hospitalized. The nurse discovers fetor hepaticus when the nurse performs which part of the client's assessment? a) assessment of the client's urine b) assessment of the client's stool c) assessment of the client's hands d) assessment of the client's breath

d

A patient rapidly progressing toward end-stage kidney disease asks about the possibility of a kidney transplant. In responding to the patient, the nurse knows that what is a contraindication to kidney transplantation? a. Hepatitis C infection b. Coronary artery disease c. Refractory hypertension d. Extensive vascular disease

d

Priority Decision: What is the most appropriate snack for the nurse to offer a patient with stage 4 CKD? a. Raisins b. Ice cream c. Dill pickles d. Hard candy

d

A client has a diagnosis of superficial partial thickness burns. The client asks which layers of skin are involved with this type of burn. Which response by the nurse is appropriate? a) the epidermis is damaged b) the dermis is damaged partially c) the structures beneath the skin are destroyed d) both the epidermis and the dermis are destroyed

a

A client arrived in the emergency department with a posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. Which score on the glasgow coma scale (GCS) would the nurse document.

3

A client with a head injury has a fixed, dilated right pupil, responds only to painful stimuli, and exhibits flexion (decorticate) posturing. Which possible cause would the nurse suspect from these clinical findings? a) meningeal irritaion b) subdural hemorrhage c) cerebral compression d) medullary compression

c

A 68-year-old man with a history of heart failure resulting from hypertension has AKI as a result of the effects ofnephrotoxic diuretics. Currently his serum potassium is 6.2 mEq/L (6.2 mmol/L) with cardiac changes, his BUNis 108 mg/dL (38.6 mmol/L), his serum creatinine is 4.1 mg/dL (362 mmol/L), and his serum HCO3− is 14 mEq/L(14 mmol/L). He is somnolent and disoriented. Which treatment should the nurse expect to be used for him? a. Loop diuretics b. Renal replacement therapy c. Insulin and sodium bicarbonate d. Sodium polystyrene sulfonate (Kayexalate)

b

A client is admitted to the hospital for acute gastritis and ascites secondary to alcohol use and cirrhosis. For which condition is it most important for the nurse to assess in the client? a) nausea b) blood in the stool c) food intolerances d) hourly urinary output

b

Which complication of chronic kidney disease is treated with erythropoietin (EPO)? a. Anemia b. Hypertension c. Hyperkalemia d. Mineral and bone disorder

a

The patient with CKD asks why she is receiving nifedipine (Procardia) and furosemide (Lasix). The nurse understands that these drugs are being used to treat the patient's a. anemia. b. hypertension. c. hyperkalemia. d. mineral and bone disorder.

b

A client admitted with a burn injury has erythema and mild swelling. Which type of burn would the nurse suspect? a) first degree burn b) third degree burn c) fourth degree burn d) second degree burn

a

A client who has a spinal cord injury at the T4 level wants to use a wheelchair. What exercise would the nurse teach the client to do in preparation for this activity? a) push-ups to strengthen arm muscles b) leg lifts to prevent hip contractures c) balancing exercises to promote equilibrium d) quadriceps-setting exercises to maintain muscle ton

a

A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. Which intervention would the nurse do to prepare the client for the procedure? a) instruct the client to void b) tell the client not to eat for 4 hours c) give the client an analgesic d) have the client turn to the lateral position

a

A patient received a kidney transplant last month. Because of the effects of immunosuppressive drugs and CKD,what complication of transplantation should the nurse be assessing the patient for to decrease the risk of mortality? a. Infection b. Rejection c. Malignancy d. Cardiovascular disease

a

A client who has experienced a subarachnoid hemorrhage would be maintained in which position? a) supine b) on the unaffected side c) in bed with the head of bed elevated d) with sandbags on either side of the head

c

The nurse is caring for a client who sustained a partial thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. Which primary short term outcome established by the nurse and client will be added to the care plan? a) The client's airway will remain patent b) the client's burns will heal free of infection c) the client's urine output will exceed 30mL every hour d) the client's pain will remain at 2 or less on a scale of 0 to 10

d

The nurse provides education for a client with cirrhosis of the liver who has a prolonged PT and a low platelet count. A regular diet is prescribed. Which instruction would the nurse include in the teaching? a) avoid foods high in phytonadione b) check the pulse several times a day c) drink a glass of milk when taking aspirin d) report signs of bleeding no matter how slight

d

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? a) dehydration b) skin breakdown c) electrolyte imbalances d) urinary tract infections

d

The client who sustained a burn asks, 'what is thew difference between my full thickness and deep partial thickness burns? Which information will the nurse share with the client? a) full thickness burns extend into the subcutaneous tissue; deep partial-thickness burns affect only the epidermis b) full thickness burns involve superficial layers of the epidermis; deep partial thickness burns extend through the epidermis; deep partial thickness burns extend through the epidermis c) full thickness burns extend through the epidermis and only part of the dermis; deep partial-thickness burns extend into the subcutaneous tissue d) full thickness burns extend into the subcutaneous tissue; deep partial thickness burns extend through the epidermis and involve only part of the dermis

d

The nurse is caring for a client 1 week after the client experienced a spinal cord injury at the T3 level. Which short term goal is appropriate in planning care for this client? a) the client will understand limitations b) the client will consider lifestyle changes c) the client will perform independent ambulation d) the client will carry out personal hygiene activities

d