N3 Quiz 4

A patient has acute kidney injury (AKI) with a negative nitrogen balance. How much weight does the nurse expect the patient to lose? 0.5 kg/day 1.0 kg/day 1.5 kg/day 2.0 kg/day

0.5 kg/day Explanation: AKI causes severe nutritional imbalances (because nausea and vomiting contribute to inadequate dietary intake), impaired glucose use and protein synthesis, and increased tissue catabolism. The patient is weighed daily and loses 0.2 to 0.5 kg (0.5 to 1 lb) daily if the nitrogen balance is negative (i.e., caloric intake falls below caloric requirements).

The nurse notes that a patient who is retaining fluid had a 1-kg weight gain. The nurse knows that this is equivalent to about how many mL? 250 mL 500 mL 750 mL 1,000 mL

1,000 mL

Cholesterol stones account for what percentage of cases of gallbladder disease in the United States? 15% 25% 60% 75%

75%

A client admitted with severe epigastric abdominal pain radiating to the back is vomiting and reports difficulty breathing. Upon assessment, the nurse determines that the client is experiencing tachycardia and hypotension. Which actions are priority interventions for this client? Select all that apply. Administer pain-relieving medication Administer a low-fat diet Administer electrolytes Administer plasma Assist the client to a semi-Fowler position

Administer pain-relieving medication Administer electrolytes Administer plasma Assist the client to a semi-Fowler position

The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level? Administration of an insulin drip Administration of a loop diuretic Administration of sodium bicarbonate Administration of sodium polystyrene sulfonate [Kayexalate])

Administration of sodium polystyrene sulfonate [Kayexalate]) Explanation: The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? Creatinine Urobilinogen Chloride Albumin

Albumin Explanation: Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

The nurse is able to identify which condition as uremia? An excess of urea in the blood An excess of protein in the blood An excess of blood in the urine An excess of protein in the urine

An excess of urea in the blood Explanation: Uremia is an excess of urea and other nitrogenous wastes in the blood. Azotemia is the concentration of nitrogenous wastes in the blood. Hematuria is blood in the urine. Proteinuria is protein in the urine. Hyperproteinemia is an excess of protein in the blood.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client? Assisting the client to turn, cough, and deep breathe every 2 hours Teaching the client to choose low-fat foods from the menu Performing range-of-motion (ROM) leg exercises hourly while the client is awake Assisting the client to ambulate the evening of the operative day

Assisting the client to turn, cough, and deep breathe every 2 hours Explanation: Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation

Which foods should be avoided following acute gallbladder inflammation? Cooked fruits Cheese Coffee Mashed potatoes

Cheese Explanation: The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

A client has undergone diagnostic testing that involved the insertion of a lighted tube with a telescopic lens. The nurse identifies this test as which of the following? Renal angiography Intravenous pyelography Excretory urogram Cystoscopy

Cystoscopy Explanation: Cystoscopy is the visual examination of the inside of the bladder using an instrument called a cystoscope, a lighted tube with a telescopic lens. Renal angiography involves the passage of a catheter up the femoral artery into the aorta to the level of the renal vessels. Intravenous pyelography or excretory urography is a radiologic study that involves the use of a contrast medium to evaluate the kidneys' ability to excrete it.

Which is an age-related change of the hepatobiliary system? Increased drug clearance capability Decreased blood flow Enlarged liver Decreased prevalence of gallstones

Decreased blood flow Explanation: Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gall stones, and a steady decrease in the size and weight of the liver.

What is the most appropriate nursing diagnosis for the client with acute pancreatitis? Deficient fluid volume Excess fluid volume Decreased cardiac output Ineffective gastrointestinal tissue perfusion

Deficient fluid volume Explanation: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

Volume status with acute pancreatitis?

Dehydration/deficit due to vomiting from pain

A nurse who works in a clinic sees many patients with a variety of medical conditions. The nurse understands that a risk factor for UTIs is which of the following? Hyperuricemia Pancreatitis Diabetes mellitus Hyperparathyroidism

Diabetes mellitus Explanation: Increased urinary glucose levels create an infection-prone environment in the urinary tract.

The nurse is caring for a client with suspected chronic pancreatitis. Which diagnostic test or imaging does the nurse recognize as the most useful in diagnosing this condition? ERCP MRI CT Ultrasound

ERCP Explanation: The ERCP is the most useful study in the diagnosis of chronic pancreatitis. The other answer choices may be used; however, these are not the most useful in the diagnosis of chronic pancreatitis.

Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure? Glomerulonephritis Hypovolemia Ureteral calculus Dysrhythmia

Glomerulonephritis Explanation: Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.

The nurse recognizes which condition as an integumentary manifestation of chronic renal failure? Asterixis Gray-bronze skin color Tremors Seizures

Gray-bronze skin color Explanation: Integumentary manifestations of chronic renal failure include a gray-bronze skin color. Other manifestations are dry, flaky skin, pruritus, ecchymosis, purpura, thin, brittle nails, and coarse, thinning hair. Asterixis, tremors, and seizures are neurologic manifestations of chronic renal failure.

Type of jaundice that is a result of an increase destruction of the red blood cells the effect is that the plasma is rapidly flooded with bilirubin so the liver although functioning normally cannot excrete the bilirubin as quickly as it is formed this type of jaundice is encountered in patients with transfusion reactions.

Hemolytic

The patient admitted with acute pancreatitis has passed the acute stage and is now able to tolerate solid foods. What type of diet will increase caloric intake without stimulating pancreatic enzymes beyond the ability of the pancreas to respond? Low-sodium, high-potassium, low-fat diet High-carbohydrate, high-protein, low-fat diet Low-carbohydrate, high-potassium diet High-carbohydrate, low-protein, low-fat diet

High-carbohydrate, low-protein, low-fat diet Explanation: The nurse should provide a high-carbohydrate, low-protein, low-fat diet when tolerated. These foods increase caloric intake without stimulating pancreatic secretions beyond the ability of the pancreas to respond.

Clinical manifestations of common bile duct obstruction include all of the following except: Light-colored urine Clay-colored feces Pruritus Jaundice

Light-colored urine Explanation: The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, or clay-colored. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. If it goes untreated jaundice and pruritus can occur.

Which enzyme aids in the digestion of fats? Lipase Amylase Secretin Trypsin

Lipase Explanation: Lipase is a pancreatic enzyme that aids in the digestion of fats. Amylase aids in the digestion of carbohydrates. Secretin is responsible for stimulating secretion of pancreatic juice. Trypsin aids in the digestion of protein.

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? Report the condition to the physician immediately. Measure abdominal girth according to a set routine. Provide the client with nonprescription laxatives. Ask the client about food intake.

Measure abdominal girth according to a set routine. Explanation: If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding ingestion of medications? metabolism of medications need for increased drug dosages need for more frequently divided doses medications becoming ineffective in clients with liver disease

Metabolism of meds. Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client? Octreotide Spironolactone Propranolol Lactulose

Octreotide Explanation: In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Octreotide (Sandostatin) causes selective splanchnic vasoconstriction by inhibiting glucagon release and is used mainly in the management of active hemorrhage. Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in clients with known varices and to prevent rebleeding. Beta-blockers should not be used in acute variceal hemorrhage, but they are effective prophylaxis against such an episode.

Which assessment findings confirm the diagnosis of acute pancreatitis? Pain with abdominal distention and hypotension Presence of blood in the client's stool and recent hypertension Presence of easy bruising and bradycardia Adventitious breath sounds and hypertension

Pain with abdominal distention and hypotension

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis? Shock Pancreatic necrosis MODS Tetany

Pancreatic necrosis Explanation: Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause of morbidity and mortality in clients with acute pancreatitis.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? Appendicitis Pancreatitis Cholecystitis Peptic ulcer

Pancreatitis Explanation: Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

A woman comes to her health care provider's office with signs and symptoms of kidney stones. Which of the following should be the primary medical management goal? Determine the stone type. Relieve any obstruction. Relieve the pain. Prevent nephron destruction.

Relieve the pain. Explanation: The immediate objective is to relieve pain, which can be incapacitating depending on the location of the stone.

Which of the following hormones is secreted by the juxtaglomerular apparatus? Renin Aldosterone Antidiuretic hormone (ADH) Calcitonin

Renin Explanation: Renin is a hormone directly involved in the control of arterial blood pressure; it is essential for proper functioning of the glomerulus. ADH, also known as vasopressin, plays a key role in the regulation of extracellular fluid by excreting or retaining water. Calcitonin regulates calcium and phosphorous metabolism.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? Monitor pulse oximetry every hour. Withhold oral feedings for the client. Instruct the client to avoid coughing. Reposition the client every 2 hours.

Reposition the client every 2 hours. Explanation: Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

Following percutaneous nephrolithotomy, the client is at greatest risk for which nursing diagnosis? Risk for altered urinary elimination Risk for deficient knowledge: self-catherization Risk for fluid volume excess Risk for infection

Risk for infection Explanation: Percutaneous nephrolithotomy is an invasive procedure for the removal of renal calculi. The client would be at risk for infection.

A client has a tumor of the head of the pancreas. What clinical manifestations will the nurse assess? Select all that apply. Clay-colored stools Dark urine Jaundice Weight gain Persistent hiccups

Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result if the tumor obstructs the entry of bile to the gastrointestinal tract. Abdominal discomfort or pain and pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected. Persistent hiccups are seen with stomach and bowel diseases.

What is used to decrease potassium level seen in acute renal failure? Sodium polystyrene sulfonate Sorbitol IV dextrose 50% Calcium supplements

Sodium polystyrene sulfonate Explanation: The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.

Gynecomastia is a common side effect of which of the following diuretics? Spironolactone Furosemide Vasopressin Nitroglycerin (IV)

Spironolactone Explanation: Gynecomastia is a common side effect caused by spironolactone. Vasopressin is used for bleeding esophageal varices and is not a diuretic. Nitroglycerin (IV) may be used with vasopressin to counteract the effects of vasoconstriction from the vasopressin.

A client has undergone a renal transplant and returns to the health care agency for a follow-up evaluation. Which finding would lead the nurse to suspect that the client is experiencing rejection? Hypotension Weight loss Polyuria Tenderness over transplant site

Tenderness over transplant site Explanation: Signs and symptoms of transplant rejection include abdominal pain, hypertension, weight gain, oliguria, edema, fever, increased serum creatinine levels, and swelling or tenderness over the transplanted kidney site.

The nurse advises a patient with renal stones to avoid eating shellfish, asparagus, and organ meats. She emphasizes these foods because she knows that his renal stones are composed of which of the following substances? Calcium Uric acid Struvite Cystine

Uric acid Explanation: Uric acid stones are found in patients with gout and myeloproliferative disorders. Therefore, a diet low in purines is recommended.

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? Spironolactone Vasopressin Nitroglycerin Cimetidine

Vasopressin Explanation: Vasopressin may be the initial therapy for esophageal varices because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client? Vitamin A Thiamine Riboflavin Vitamin K

Vitamin A Explanation: Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes.

The digestion of carbohydrates is aided by lipase. amylase. trypsin. secretin.

amylase. Explanation: Amylase is secreted by the exocrine pancreas. Lipase aids in the digestion of fats. Trypsin aids in the digestion of proteins. Secretin is the major stimulus for increased bicarbonate secretion from the pancreas.

The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status?

avoid inflamming the pancreas

enuresis

bed-wetting; urinary incontinence

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: cannot tolerate high-glucose concentration. are at risk for gallbladder contraction. are at risk for hepatic encephalopathy. can digest high-fat foods.

cannot tolerate high-glucose concentration. Explanation: Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

The nurse monitors the client for potential complications during dialysis but recognizes NOT to monitor for muscle cramping. hypertension. dysrhythmias. air embolism.

hypertension. Explanation: The nurse should monitor for hypotension, not hypertension, during the treatment related to the removal of fluid. Muscle cramping may occur late in dialysis as fluid and electrolytes rapidly leave the extracellular space. Dysrhythmias may result from electrolyte and pH changes or removal of antiarrhythmic medications. Air embolism is rare, but could occur if air enters the vascular system.

What causes portal hypertension

obstruction of the portal circulation within the damaged liver.

Most of the liver's metabolic functions are performed by: parenchymal cells. Kupffer cells. islets of Langerhans. canaliculi cells.

parenchymal cells. Explanation: The parenchymal cells perform most of the liver's metabolic functions

A client has been diagnosed with acute glomerulonephritis. This condition causes: proteinuria. pyuria. polyuria. No option is correct.

proteinuria. Explanation: The disruption of membrane permeability causes red blood cells (RBCs) and protein molecules to filter from the glomeruli into Bowman's capsule and eventually become lost in the urine. Pyuria is pus in the urine. Polyuria is an increased volume of urine voided.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: yellow sclerae. light amber urine. circumoral pallor. black, tarry stools.

yellow sclerae. Explanation: Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

A client with urinary tract infection is prescribed phenazopyridine (Pyridium). Which of the following instructions would the nurse give the client? "This medication will relieve your pain." "This medication should be taken at bedtime." "This medication will prevent re-infection." "This will kill the organism causing the infection."

"This medication will relieve your pain." Explanation: Phenazopyridine (Pyridium) is a urinary analgesic agent used for the treatment of burning and pain associated with UTIs.

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: Acetaminophen Ibuprofen Dextromethorphan Benadryl

Acetaminophen Explanation: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Acute pain related to biliary spasms Deficient knowledge related to prevention of disease recurrence Anxiety related to unknown outcome of hospitalization Imbalanced nutrition: Less than body requirements related to biliary inflammation

Acute pain related to biliary spasms Explanation: The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have? Hypertension Bile-stained vomiting Warm, dry skin Weight loss

Bile-stained vomiting Explanation: Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. The nurse documents this finding as which of the following? Gynecomastia Cutaneous spider angioma Caput medusae Palmar erythema

Caput medusae Explanation: Caput medusa is a term used to denote the appearance of dilated veins over the client's abdomen. Gynecomastia refers to enlarged breasts in a male, which may occur because the dysfunctional liver is unable to metabolize estrogen. Palmer erythema refers to the bright pink appearance of the palms and cutaneous spider angioma refers to tiny, spider-like blood vessels that may be apparent in a client with cirrhosis due to the liver's inability to inactivate estrogen.

Which foods should be avoided following acute gallbladder inflammation? Cooked fruits Cheese Coffee Mashed potatoes

Cheese Explanation: The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated. Reference:

The nurse is encouraging the client with recurrent urinary tract infections to increase fluid intake to 8 large glasses of fluids daily. Which beverage would the nurse discourage for this client? Coffee in the morning Fruit juice midmorning Milk at lunch Ginger ale at dinner time

Coffee in the morning Explanation: The nurse would discourage drinking coffee. Coffee, tea, alcohol, and colas are urinary tract irritants. Fruit juice, milk, and ginger ale are appropriate for drinking and counted toward the daily fluid total.

When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate? Cola-colored urine Left upper quadrant pain Pyuria Low blood pressure

Cola-colored urine Explanation: Cola-colored urine is a typical symptom of glomerulonephritis. Flank pain on the affected side, not left upper quadrant pain, would be present. Pyuria is a symptom of pyelonephritis, not glomerulonephritis. Blood pressure typically elevates in glomerulonephritis.

A client seeks medical attention for severe abdominal and back pain that is unrelieved with antacids. Which assessment finding indicates to the nurse that the client is experiencing acute pancreatitis? Diarrhea Heartburn Right shoulder pain Ecchymosis around the umbilicus

Ecchymosis around the umbilicus Explanation: Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. Abdominal pain and tenderness and back pain are caused by irritation and edema of the inflamed pancreas. Ecchymosis (bruising) around the umbilicus may indicate severe pancreatitis. Diarrhea and heartburn are not symptoms of acute pancreatitis. Right shoulder pain is associated with gallbladder disease.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find? Increased serum calcium levels Elevated urine amylase levels Decreased liver enzyme levels Decreased white blood cell count

Elevated urine amylase levels Explanation: Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence? Encouraging intake of at least 2 L of fluid daily Giving the client a glass of soda before bedtime Taking the client to the bathroom twice per day Consulting with a dietitian

Encouraging intake of at least 2 L of fluid daily Explanation: Encouraging a daily fluid intake of at least 2 L helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary

Which of the following is a cause of a calcium renal stone? Excessive intake of vitamin D Gout Neurogenic bladder Foreign bodies

Excessive intake of vitamin D Explanation: Potential causes of calcium renal stones include excessive intake of vitamin D, hypercalcemia, hyperparathyroidism, excessive intake of milk and alkali, and renal tubular acidosis. Gout is associated with uric acid. Struvite stones are associated with neurogenic bladder and foreign bodies.

A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction? Paracentesis Liver transplantation High-dose corticosteroids Azathioprine

High-dose corticosteroids Explanation: Drug-induced hepatitis occurs when a drug reaction damages the liver. This form of hepatitis can be severe and fatal. High-dose corticosteroids usually administered first to treat the reaction. Liver transplantation may be necessary. Paracentesis would be used to withdraw fluid for the treatment of ascites. Azathioprine (Imuran) may be used for autoimmune hepatitis.

A client with chronic kidney disease reports generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures? Elevated serum creatinine Hyperkalemia Hyperphosphatemia Elevated urea and nitrogen

Hyperphosphatemia Osteodystrophy is a condition in which the bone becomes demineralized due to hypocalcemia and hyperphosphatemia. In an effort to raise blood calcium levels, the parathyroid glands secrete more parathormone. Elevated creatinine, urea, nitrogen, and potassium levels are expected in chronic renal failure and do not contribute to bone fractures

The nurse is caring for a client diagnosed with bladder cancer and requiring a cystectomy. The nurse overhears the physician instructing the client on the presence of a stoma with temporary pouch. In gathering information for the client, which urinary diversion would the nurse select? Ileal conduit Kock Pouch Ureterosigmoidostomy Indiana Pouch

Ileal conduit Explanation: When the physician is discussing a stoma, the nurse recognizes that the client will have an ileal conduit which is a cetaceous urinary diversion. Both the Kock Pouch and Indiana Pouch are continent urinary diversions. The ureterosigmoidostomy connects with the rectum for urinary drainage.

The assessment of a client admitted with increased ascites related to cirrhosis reveals the following: pulse 86 beats per minute and weak, respirations 28 breaths per minute, blood pressure 130/88 mm Hg, and pulse oximetry 90%. Which nursing diagnosis should receive top priority? Fatigue Excess fluid volume Ineffective breathing pattern Imbalanced nutrition: less than body requirements

Ineffective breathing pattern Explanation: In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia. Although fluid volume excess is present, the respiratory rate and low oxygen saturation would indicate the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern.

What is administered to reduce serum ammonia levels?

Lactulose (Cephulac)

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? Encouraging coughing and deep breathing Promoting carbohydrate intake Limiting fluid intake Providing pain-relief measures

Limiting fluid intake Explanation: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and IV fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.

A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the client has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this client is what? IV administration of immune globulins Transfusion of packed red blood cells and fresh-frozen plasma (FFP) Liver transplantation Lobectomy

Liver transplantation Explanation: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.

A client recovering from hepatitis B develops acute nephrotic syndrome. Which treatment will the nurse anticipate being prescribed for this client? Vancomycin Methylprednisolone Increase in sodium intake Low-carbohydrate diet

Methylprednisolone Explanation: Acute nephritic syndrome is a type of acute glomerulonephritis. The focus of management is to treat symptoms, preserve kidney function, and treat complications. Treatment may include corticosteroids such as methylprednisolone. Antibiotics such as vancomycin are used to treat bacterial infections. Hepatitis B is caused by a virus. Sodium would be restricted if the client has hypertension, edema, or heart failure. Carbohydrates should be ingested liberally to provide energy and reduce the catabolism of protein.

The nurse is caring for a postoperative client who has a Kock pouch. Nursing assessment findings reveal abdominal pain, absence of bowel sounds, fever, tachycardia, and tachypnea. The nurse suspects which of the following? Stoma ischemia Postoperative pneumonia Stoma retraction Peritonitis

Peritonitis Explanation: Clinical manifestations of peritonitis include abdominal pain and distention, absence of bowel sounds, nausea and vomiting, fever, changes in vital signs.

After undergoing a liver biopsy, a client should be placed in which position? Semi-Fowler's position Right lateral decubitus position Supine position Prone position

Right lateral decubitus position Explanation: After a liver biopsy, the client is placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. Semi-Fowler's position and the supine and prone positions wouldn't achieve this goal.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? Impaired urinary elimination Toileting self-care deficit Risk for infection Activity intolerance

Risk for infection Explanation: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? The client's hepatic function is decreasing. The client didn't take his morning dose of lactulose (Cephulac). The client is relaxed and not in pain. The client is avoiding the nurse.

The client's hepatic function is decreasing. Explanation: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain. When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness? The upper abdominal quadrants on the left and right side The costovertebral angle Above the symphysis pubis Around the umbilicus

The costovertebral angle Explanation: The nurse is correct to assess the kidneys for tenderness at the costovertebral angle. The other options are incorrect.

Describe the 4 stages of acute renal failure

The onset phase is accompanied by reduced blood flow to the nephrons. In the oliguric phase, fluid volume excess develops, which leads to edema, hypertension, and cardiopulmonary complications. During the diuretic phase, excretion of wastes and electrolytes continues to be impaired despite increased water content of the urine. During the recovery phase, normal glomerular filtration and tubular function are restored.

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient? The patient requires more pain medication. The patient is developing a paralytic ileus. The patient has developed peritonitis. The patient has developed renal failure.

The patient has developed peritonitis. Explanation: Abdominal guarding is present. A rigid or board-like abdomen may develop and is generally an ominous sign, usually indicating peritonitis

A client with chronic kidney disease weighs 209 lbs (95 kg) and is prescribed 1.2 grams of protein per kg per day. Which amount of protein will the client ingest per day?

To calculate the amount of protein the client is to ingest per day, first determine the client's weight in kg by dividing the weight in lbs by 2.2 or 209/2.2 = 95 kg. Then multiply the client's weight in kg by 1.2 or 95 x 1.2 = 114 grams. The client is to ingest 114 grams of protein per day.

The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose? Watery diarrhea Vomiting Ringing in the ears Asterixis

Watery diarrhea Explanation: The patient receiving lactulose is monitored closely for the development of watery diarrhea stools, because they indicate a medication overdose. Serum ammonia levels are closely monitored as well.

A client with chronic pancreatitis is treated for uncontrolled pain. Which complication does the nurse recognize is most common in the client with chronic pancreatitis? Weight loss Diarrhea Fatigue Hypertension

Weight loss Explanation: Weight loss is most common in the client with chronic pancreatitis due to decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack. The other answer choices are not the most common complications related to chronic pancreatitis.

A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: limit oral fluid intake for 1 to 2 weeks. report the presence of fine, sandlike particles through the nephrostomy tube. notify the physician about cloudy or foul-smelling urine. report bright pink urine within 24 hours after the procedure.

notify the physician about cloudy or foul-smelling urine. Explanation: The nurse should instruct the client to report the presence of foul-smelling or cloudy urine to the physician. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal because of residual stone products. Hematuria is common after lithotripsy. Reference:

Which condition or laboratory result supports a diagnosis of pyelonephritis? Myoglobinuria Ketonuria Pyuria Low white blood cell (WBC) count

py·u·ri·a the presence of pus in the urine, typically from bacterial infection.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: elevated liver enzymes and low serum protein level. subnormal serum glucose and elevated serum ammonia levels. subnormal clotting factors and platelet count. elevated blood urea nitrogen and creatinine levels and hyperglycemia.

subnormal serum glucose and elevated serum ammonia levels. Explanation: In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness.

A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock should be reported to the healthcare provider? tachycardia and tachypnea tachycardia and bradypnea bradycardia and bradypnea bradycardia and tachypnea

tachycardia and tachypnea Explanation: The compensatory stage is the first stage of shock. During this stage, the sympathetic nervous system (SNS) is activated due to changes in blood volume and blood pressure. The SNS stimulates the cardiovascular system, causing tachycardia, and the respiratory system, causing tachypnea. Thus, tachycardia (not bradycardia) and tachypnea (not bradypnea) occur with the compensatory stage of shock

A nurse receives her client care assignment. Following the report, she should give priority assessment to the client: with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit. who has a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L 7 days after a kidney transplant. who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L. who is experiencing mild pain from urolithiasis.

who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L. Explanation: A sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L in a client immediately following dialysis should be the priority assessment. Pinkish mucus discharge in the appliance bag is a normal finding for a client who's had an ileal conduit, as are a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L in a client who's had a kidney transplant. Although the nurse should further assess mild pain from urolithiasis, this is an expected finding and not a priority in relation to the client with abnormal sodium and potassium levels.

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood glucose level does the nurse recognize as inadequate to sustain normal brain function? 30 mg/dL 50 mg/dL 70 mg/dL 90 mg/dL

30 mg/dL Explanation: Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulin-like material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones? 1 to 4 months 4 to 6 months 6 to 12 months Over 1 year

6 to 12 months Explanation: Six to 12 months of therapy with UDCA is recommended in clients to dissolve the stones.

A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder? Acute renal failure Acute glomerulonephritis Chronic renal failure Nephrotic syndrome

Acute glomerulonephritis Explanation: Acute glomerulonephritis is also associated with varicella zoster virus, hepatitis B, and Epstein-Barr virus. Acute renal failure is associated with hypoperfusion to the kidney, parenchymal damage to the glomeruli or tubules, and obstruction at a point distal to the kidney. Chronic renal failure may be caused by systemic disease, hereditary lesions, toxic agents, infections, and medications. Nephrotic syndrome is caused by disorders such as chronic glomerulonephritis, systemic lupus erythematosus, multiple myeloma, and renal vein thrombosis.

A client is diagnosed with a disorder that affects pancreatic digestive enzymes, and their typsin levels are elevated. The client has jaudice and verbalizes severe abdominal pain. The nurse most likely anticipates which condition? Acute pancreatitis Choledochostomy Steatorrhea Cholecysitis

Acute pancreatitis

Following a renal biopsy, a client reports severe pain in the back, the arms, and the shoulders. Which intervention should be offered by the nurse? Assess the patient's back and shoulder areas for signs of internal bleeding. Distract the client's attention from the pain. Provide analgesics to the client. Enable the client to sit up and ambulate.

Assess the patient's back and shoulder areas for signs of internal bleeding. Explanation: After a renal biopsy, the client should be on bed rest. The nurse observes the urine for signs of hematuria. It is important to assess the dressing frequently for signs of bleeding, monitor vital signs, and evaluate the type and severity of pain. Severe pain in the back, shoulder, or abdomen may indicate bleeding. In such a case, the nurse should notify the physician about these signs and symptoms. The nurse should also assess the client for difficulty voiding and encourage adequate fluid intake.

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have? Hypertension Bile-stained vomiting Warm, dry skin Weight loss

Bile-stained vomiting Explanation: Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

The nurse is providing care to a client who has had a kidney biopsy. The nurse would need to be alert for signs and symptoms of which of the following? Bleeding Infection Dehydration Allergic reaction

Bleeding Explanation: Renal biopsy carries the risk of post procedure bleeding, because the kidneys receive up to 25% of the cardiac output each minute. Therefore, the nurse would need to be alert for signs and symptoms of bleeding. Although infection is also a risk, the risk for bleeding is greater. Dehydration and allergic reaction are not associated with a renal biopsy.

A client requires hemodialysis. Which type of drug should be withheld before this procedure? Phosphate binders Insulin Antibiotics Cardiac glycosides

Cardiac glycosides such as digoxin (Lanoxin) should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digoxin toxicity. Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: cirrhosis. peptic ulcer disease. appendicitis. cholelithiasis.

Cirrhosis Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal

Based on her knowledge of the primary cause of end-stage renal disease, the nurse knows to assess the most important indicator. What is that indicator? Blood pressure Urine protein Serum glucose pH and HCO3

Serum glucose Explanation: The nurse would evaluate serum and urine levels of glucose because diabetes is the primary cause of renal failure.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from: The digestion of dietary and blood proteins. Excessive diuresis and dehydration. Severe infections and high fevers. Excess potassium loss subsequent to prolonged use of diuretics.

The digestion of dietary and blood proteins. Explanation: Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (i.e., bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.

A client presents at the clinic with reports of urinary retention. What question should the nurse ask to obtain additional information about the client's report? "Have you had a fever and chills?" "How much fluid are you drinking?" "Do you get up at night to urinate?" "When did you last urinate?"

"When did you last urinate?" Explanation: The nurse needs to determine the last time the client voided.

Which medication may be ordered to relieve discomfort associated with a UTI? Nitrofurantoin Phenazopyridine Ciprofloxacin Levofloxacin

Phenazopyridine Explanation: Phenazopyridine is a urinary analgesic ordered to relieve discomfort associated with UTIs. Nitrofurantoin, ciprofloxacin, and levofloxacin are antibiotics.

The nurse is providing discharge instructions to the client with acute post-streptococcal glomerulonephritis. Which statement by the client indicates a need for further teaching? "I should limit foods high in potassium in my diet, such as bananas." "I should limit the amount of protein in my diet." "I should drink as much as possible to keep my kidneys working." "My intake of high sodium foods should be limited."

"I should drink as much as possible to keep my kidneys working." Explanation: Dietary management of acute post-streptococcal glomerulonephritis includes restrictions of protein, sodium, potassium, and fluids.

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment? "The tube helps control fluid and electrolyte imbalance." "The tube provides relief from nausea and vomiting." "The tube allows the gastrointestinal tract to rest." "The tube allows toxins to be removed."

"The tube allows the gastrointestinal tract to rest." Explanation: Postoperative management of clients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of clients after extensive gastrointestinal or biliary surgery. An NG tube with suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.

Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve? 1 to 2 3 to 5 6 to 12 13 to 18

6 to 12 Explanation: Ursodeoxycholic acid (UDCA [URSO, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. Six to 12 months of therapy are required in many clients to dissolve stones, and monitoring of the client for recurrence of symptoms or occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

The nurse is caring for a client recovering from acute pancreatitis. Which menu item should the nurse remove from the client's breakfast tray? Toast Coffee Oatmeal Orange slices

Coffee Explanation: Post-acute management of the client with acute pancreatitis includes the introduction of solid food. Oral feedings that are low in fat and protein are gradually initiated. Caffeine is eliminated from the diet and therefore coffee, which contains caffeine, should be removed from the client's breakfast tray. Even decaffeinated coffee has a small amount of caffeine but could serve as a compromise for chronic coffee drinkers. The other food items are appropriate for the client.

Which of the following would be least appropriate to suggest to a client with a urinary diversion to control odor? Avoid foods such as buttermilk or yogurt. Eat plenty of cheese and eggs. Avoid pouches with carbon filters. Add a few drops of diluted white vinegar to the pouch.

Eat plenty of cheese and eggs. Explanation: To help control odor, the client should use pouches with carbon filters or other odor barriers or add a few drops of liquid deodorizer or diluted white vinegar to the pouch. Foods such as cranberry juice, yogurt or buttermilk may help to decrease odor while foods such as asparagus, cheese, and eggs may impart an odor to the urine. Reference:

—————— is manifested by numerous central nervous system effects including disorientation, confusion, mood swings, reversed day-night sleep patterns with sleep occurring during the day, agitation, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (referred to as fetor hepaticus), and lethargy. As it becomes more severe, the client becomes stuporous and eventually comatose.

Hepatic encephalopathy

This type of jaundice is caused by the inability of damaged liver cells to clear normal amounts of bilirubin from the blood. Cellular damage may be caused by hepatitis virus, or other viruses that affect the liver such as yellow fever virus, Epstein-Barr virus, chemical toxins.

Hepatocellular jaundice

A client with chronic kidney disease becomes confused and reports abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which lab value? Elevated urea levels Hyperkalemia Hypocalcemia Elevated white blood cells

Hyperkalemia Explanation: Hyperkalemia is the life-threatening effect of renal failure. The client can become apathetic; confused; and have abdominal cramping, dysrhythmias, nausea, muscle weakness, and numbness of the extremities. Symptoms of hypocalcemia are muscle twitching, irritability, and tetany. Elevation in urea levels can result in azotemia, which can be exhibited in fluid and electrolyte and/or acid-base imbalance. Elevation of WBCs is not indicated.

The nurse is caring for a client who has ascites as a result of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing? Select all that apply. Measure urine output every 8 hours. Assess and document vital signs every 4 hours. Measure abdominal girth daily. Perform daily weights. Monitor number of bowel movements per day.

If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion.

A client has undergone a liver biopsy. Which postprocedure position is appropriate? On the left side Trendelenburg On the right side High Fowler

In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on his left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan? Increase respiratory effectiveness. Eliminate the need for nasogastric intubation. Improve nutritional status during recovery. Decrease the amount of postoperative analgesia needed.

Increase respiratory effectiveness. Explanation: The nurse must teach the client about using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients don't have a nasogastric tube in place after a cholecystectomy. It isn't appropriate to teach improved nutritional status before surgery. It isn't important for the client to be aware of how to decrease the amount of postoperative analgesia, because this is the responsibility of the health care team.

The nurse is caring for a client with chronic pancreatitis. Which symptom would indicate the client has developed secondary diabetes? Increased appetite and thirst Vomiting and diarrhea Low blood pressure and pulse Decreased urination and constipation

Increased appetite and thirst Explanation: When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. Vomiting, diarrhea, low blood pressure and pulse, and constipation do not indicate the development of secondary diabetes.

A client diagnosed with acute kidney injury (AKI) has developed congestive heart failure. The client has received 40 mg of intravenous push (IVP) Lasix and 2 hours later, the nurse notes that there are 50 mL of urine in the Foley catheter bag. The client's vital signs are stable. Which health care order should the nurse anticipate? Lasix 80 mg IVP Normal saline bolus of 500 mL Chest x-ray Mannitol 12.5 g IVP

Lasix 80 mg IVP Explanation: Diuretic agents are often used to control fluid volume in clients with acute kidney injury (AKI). The client's urine output indicates an inadequate response to the initial dosage of Lasix and the nurse should anticipate administering Lasix 80 mg IVP. Often in this situation, the initial dosage of Lasix is doubled. The client is experiencing fluid overload, thus, a 500-mL bolus of normal saline bolus would be contraindicated. There is no need to complete a chest x-ray. Mannitol is widely used in the management of cerebral edema and increased intracranial pressure from multiple causes.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? Serum potassium level of 3.5 mEq/L Loss of 2.2 lb (1 kg) in 24 hours Serum sodium level of 135 mEq/L Blood pH of 7.25

Loss of 2.2 lb (1 kg) in 24 hours Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness.

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority? Developing no acute complications from the pancreatitis Maintaining normal respiratory function Maintaining satisfactory pain control Achieving adequate fluid and electrolyte balance

Maintaining normal respiratory function Explanation: Airway and breathing are always the priority assessment. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body's metabolic demands, which further decreases pulmonary reserve and can lead to respiratory failure. Maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? Auscultate the abdomen for bowel sounds every 4 hours Measure abdominal girth every shift Monitor for reports of nausea and vomiting Measure blood glucose concentration every 4 to 6 hours

Measure blood glucose concentration every 4 to 6 hours Explanation: Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.

A young client with anorexia, fatigue, and jaundice is diagnosed with hepatitis B and has just been admitted to the hospital. The client asks the nurse how long the stay in the hospital will be. In planning care for the client, the nurse identifies impaired psychosocial issues and assigns the highest priority to which client outcome? Minimizing social isolation Establishing a stable home environment Reducing the spread of the disease Identifying the source of exposure to hepatitis

Minimizing social isolation Explanation: The nurse identifies psychosocial issues and concerns, particularly the effects of separation from family and friends if the client is hospitalized during the acute and infective stages. Convalescence may be prolonged, with complete symptomatic recovery sometimes requiring 3 to 4 months or longer. Even if not hospitalized, the client will be unable to attend school and/or work and must avoid sexual contact. Planning is required to minimize social isolation.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? Appendicitis Pancreatitis Cholecystitis Peptic ulcer

Pancreatitis Explanation: Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection? Use a clean technique during insertion Use a sterile technique to disconnect the catheter from the tubing to obtain urine specimens Place the catheter bag on the client's abdomen when moving the client Perform meticulous perineal care daily with soap and water

Perform meticulous perineal care daily with soap and water Explanation: Cleanliness of the area will reduce potential for infection. Strict aseptic technique must be used when inserting a urinary bladder catheter. The nurse must maintain a closed system and use the catheter's port to obtain specimens. The catheter bag must never be placed on the client's abdomen unless it is clamped because it may cause urine to flow back from the tubing into the bladder.

Which of the following occurs late in chronic glomerulonephritis? Peripheral neuropathy Nosebleed Stroke Seizure

Peripheral neuropathy Explanation: Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span.

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? Respiratory assessment related to increased thoracic pressure Urinary output related to increased sodium retention Peripheral vascular assessment related to immobility Skin assessment related to increase in bile salts

Respiratory assessment related to increased thoracic pressure Explanation: If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

The nurse is caring for a postoperative client who reports difficulty urinating. The client does not have a urinary catheter in place. Which nursing action(s) are most appropriate at this time? Select all that apply. Run water to assist in the let-down reflex. Assist to the bathroom. Place a urinary catheter. Assist the client to stand. Measure urinary output.

Run water to assist in the let-down reflex. Assist to the bathroom. Assist the client to stand. Measure urinary output. The nurse encourages the client to void within 8 hours of surgery to minimize the risk of a urinary tract infection. Ambulating the client to the bathroom promotes normal body positioning for urination. Running water is a common psychological strategy to cause urination. Offering to catheterize is a last option, and a prescription for catheterization must be in place for the nurse to proceed.

A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test?

Serum amylase Explanation: Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason? To decrease metabolism To depress the central nervous system and increase the pain threshold To reduce gastric and pancreatic secretions To relieve nausea and vomiting

To reduce gastric and pancreatic secretions Explanation: Anticholinergic medications reduce gastric and pancreatic secretion.

The nurse performs acute intermittent peritoneal dialysis (PD) on a client who is experiencing uremic signs and symptoms. The peritoneal fluid is not draining as expected. What is the best response by the nurse? Notify the health care provider. Turn the client from side to side. Lower the head of the bed. Push the catheter further into the abdomen.

Turn the client from side to side. Explanation: If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the client from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. Other measures to promote drainage include checking the patency of the catheter by inspecting for kinks, closed clamps, or an air lock.

A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect? Acute glomerulonephritis Ureteral stricture Urinary calculi Renal cell carcinoma

Urinary calculi Explanation: Symptoms of a kidney or ureteral stone vary with size, location, and cause. Small stones may pass unnoticed; however, sudden, sharp, severe flank pain that travels to the suprapubic region and external genitalia is the classic symptom of urinary calculi. The pain is accompanied by renal or ureteral colic, painful spasms that attempt to move the stone. The pain comes in waves that radiate to the inguinal ring, the inner aspect of the thigh, and to the testicle or tip of the penis in men, or the urinary meatus or labia in women. Clients with acute glomerulonephritis may be asymptomatic or may exhibit fever, nausea, malaise, headache, edema (generalized or periorbital), pain, and mild to moderate hypertension. Clients with ureteral stricture may complain of flank pain and tenderness at the costovertebral angle and back or abdominal discomfort. A client with renal cell carcinoma rarely exhibits symptoms early on but may present with painless hematuria and persistent back pain in later stages.

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? Serum potassium level of 4.9 mEq/L Serum sodium level of 135 mEq/L Temperature of 99.2° F (37.3° C) Urine output of 20 ml/hour

Urine output of 20 ml/hour Explanation: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? Potassium Vitamin K Vitamin B Oral bile acids

Vitamin K Explanation: Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

The nurse recognizes that test results that most likely indicate a urinary tract infection include: proteinuria WBC 50 RBC 3 glucose trace

WBC 50 Explanation: Increased white blood cell occurs in all clients with a UTI and indicates an infectious process is occurring.

Choledocholithotomy

incision of the common bile duct for the removal of stones.