3130 EXAM #5

What is the normal lab value for Serum Creatinine?

0.6-1.2 mg/dL

A patient informs the nurse they are experiencing erectile dysfunction with difficulty in obtaining and sustaining an erection. What questions would be appropriate for the nurse to ask to obtain a history? Select all that apply. 1. "Do you have diabetes?" 2. "Are you under any major stress?" 3. "Have you been diagnosed with arthritis?" 4. "Are you taking medication for high blood pressure?" 5. "Do you take nonsteroidal antiinflammatory drugs (NSAIDs)?"

1. "Do you have diabetes?" 2. "Are you under any major stress?" 4. "Are you taking medication for high blood pressure?"

A patient arrives in the emergency department reporting severe scrotal pain, nausea, and vomiting that began one hour ago. For which diagnostic tests should the nurse prepare the patient? Select all that apply. 1. Nuclear scan 2. Doppler ultrasound 3. Transrectal ultrasound 4. Microscopic evaluation 5. Magnetic resonance imaging

1. Nuclear scan 2. Doppler ultrasound

The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient complains of "popping" in the ear. c. The patient frequently asks the nurse to repeat information. d. The patient states that the right ear has a feeling of fullness.

ANS: A The fever indicates that the infection may not be resolved and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, and decreased hearing are symptoms of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment

A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? a. Insert urethral catheter. b. Obtain renal ultrasound. c. Draw a complete blood count. d. Infuse normal saline at 50 mL/hour.

ANS: A The patient's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate, but should be implemented after the retention catheter.

The nurse is planning to teach the client with acute glomerulonephritis about necessary dietary restrictions. Which dietary changes should the nurse include in the plan? A) Limit fluid intake to 500 ml perday B) Restrict protein intake by limiting meats and other high protein foods C) Increase intake of high fiber foods, such as bran cereal. D) Increase intake of potassium-rich foods such as bananas or canteloupe

ANS: B

A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone). Which assessment data will be of most concern to the nurse? a. The blood glucose is 144 mg/dL. b. There is a nontender axillary lump. c. The patient's skin is thin and fragile. d. The patient's blood pressure is 150/92.

ANS: B A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, skin change, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy.

Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

ANS: B Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate.

The nurse will plan to teach a 27-year-old female who smokes 2 packs of cigarettes daily about the increased risk for a. kidney stones. b. bladder cancer. c. bladder infection. d. interstitial cystitis.

ANS: B Cigarette smoking is a risk factor for bladder cancer. The patient's risk for developing interstitial cystitis, urinary tract infection (UTI), or kidney stones will not be reduced by quitting smoking. DIF: Cognitive Level: Apply (application) REF: 1085-1086 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. "I will wash my hands often during the day." b. "I will remove my contact lenses at bedtime." c. "I will not share towels with my friends or family." d. "I will monitor my family for eye redness or drainage."

ANS: B Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact

When assessing a patient with a urinary tract infection, indicate on the accompanying figure where the nurse will percuss to assess for possible pyelonephritis. a. 1 b. 2 c. 3 d. 4

ANS: B Costovertebral angle (CVA) tenderness with percussion suggests pyelonephritis or polycystic kidney disease. DIF: Cognitive Level: Understand (comprehension) REF: 1054-1055 OBJ: Special Questions: Alternate item format: Hot spot TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

Which equipment will the nurse obtain to perform a Rinne test? a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch

ANS: B Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations

Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist the patient to a supine position for the irrigation. b. Fill the irrigation syringe with body-temperature solution. c. Use a sterile applicator to clean the ear canal before irrigating. d. Occlude the ear canal completely with the syringe while irrigating.

ANS: B Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cotton-tipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe

43. Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist the patient to a supine position for the irrigation. b. Fill the irrigation syringe with body-temperature solution. c. Use a sterile applicator to clean the ear canal before irrigating. d. Occlude the ear canal completely with the syringe while irrigating.

ANS: B Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cotton-tipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe.

A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question? a. NPO for 6 hours before procedure b. Ibuprofen (Advil) 400 mg PO PRN for pain c. Dulcolax suppository 4 hours before procedure d. Normal saline 500 mL IV infused before procedure

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

The nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the laboratory results of these patients. Which patient's PSA result is not expected to be elevated? a. A 38-yr-old patient who is being treated for acute prostatitis b. A 48-yr-old patient whose father died of metastatic prostate cancer c. A 52-yr-old patient who goes on long bicycle rides every weekend d. A 75-yr-old patient who uses saw palmetto to treat benign prostatic hyperplasia (BPH)

ANS: B The family history of prostate cancer and elevation of PSA indicate that further evaluation of the patient for prostate cancer is needed. Elevations in PSA for the other patients are not unusual. DIF: Cognitive Level: Apply (application) REF: 1281 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

The nurse completing a physical assessment for a newly admitted male patient is unable to feel either kidney on palpation. Which action should the nurse take next? a. Obtain a urine specimen to check for hematuria. b. Document the information on the assessment form. c. Ask the patient about any history of recent sore throat. d. Ask the health care provider about scheduling a renal ultrasound.

ANS: B The kidneys are protected by the abdominal organs, ribs, and muscles of the back, and may not be palpable under normal circumstances, so no action except to document the assessment information is needed. Asking about a recent sore throat, checking for hematuria, or obtaining a renal ultrasound may be appropriate when assessing for renal problems for some patients, but there is nothing in the question stem to indicate that they are appropriate for this patient. DIF: Cognitive Level: Apply (application) REF: 1055 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse evaluates that wearing bifocals improved the patient's myopia and presbyopia by assessing for a. strength of the eye muscles. b. both near and distant vision. c. cloudiness in the eye lenses. d. intraocular pressure changes.

ANS: B The lenses are prescribed to correct the patient's near and distant vision. The nurse may also assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patient's bifocals are effective

The nurse evaluates that wearing bifocals improved the patient's myopia and presbyopia by assessing for a. strength of the eye muscles. b. both near and distant vision. c. cloudiness in the eye lenses. d. intraocular pressure changes.

ANS: B The lenses are prescribed to correct the patient's near and distant vision. The nurse may also assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patient's bifocals are effective.

A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care? a. Disturbed body image related to eye trauma and eye patch b. Risk for falls related to temporary decrease in stereoscopic vision c. Ineffective health maintenance related to inability to see surroundings d. Ineffective denial related to inability to admit the impact of the eye injury

ANS: B The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective health maintenance, disturbed body image, or ineffective denial

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV b. Mannitol (Osmitrol) 100 mg IV c. Betaxolol (Betoptic) 1 drop in each eye d. Acetazolamide (Diamox) 250 mg orally

ANS: B The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered

A patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy should the nurse implement first? a. Infuse normal saline at 50 mL/hr. b. Insert a urinary retention catheter. c. Draw blood for a complete blood count. d. Schedule pelvic magnetic resonance imaging

ANS: B The patient data indicate that the patient may have acute kidney injury caused by the BPH. The initial therapy will be to insert a catheter. The other actions are also appropriate, but they can be implemented after the acute urinary retention is resolved. DIF: Cognitive Level: Analyze (analysis) REF: 1269 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 58-year-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which nursing diagnosis is a priority for the patient? a. Activity intolerance related to rapidly increased weight b. Excess fluid volume related to low serum protein levels c. Disturbed body image related to peripheral edema and ascites d. Altered nutrition: less than required related to protein restriction

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

Which intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein? a. Start continuous pulse oximetry. b. Restrict physical activity to bed rest. c. Restrict the patient's oral protein intake. d. Discontinue the urethral retention catheter.

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

A 79-year-old man has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care? a. Limit fluid intake to no more than 1000 mL/day. b. Leave a light on in the bathroom during the night. c. Ask the patient to use a urinal so that urine can be measured. d. Pad the patient's bed to accommodate overflow incontinence.

ANS: B The patient's age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patient's output is necessary or that the patient has overflow incontinence. DIF: Cognitive Level: Apply (application) REF: 1050-1051 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 34-year-old male patient seen at the primary care clinic complains of feeling continued fullness after voiding and a split, spraying urine stream. The nurse will ask about a history of a. recent kidney trauma. b. gonococcal urethritis. c. recurrent bladder infection. d. benign prostatic hyperplasia.

ANS: B The patient's clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection. DIF: Cognitive Level: Apply (application) REF: 1071 | 1081 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check patient's blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.

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

The nurse assesses a client post-cataract surgery and finds white, dry, crusty drainage on the client's eyelid and lashes. What does the nurse do next? a. Obtain a specimen of the drainage for culture. b. Clean away the drainage and apply the prescribed drops. c. Contact the physician for an antibiotic order. d. Arrange for the client to be seen by the ophthalmologist today.

ANS: B White, dry, crusty drainage on the eyelid and lashes is expected after cataract surgery. Because the drainage is white and no other symptoms of infection are noted, a culture does not need to be done and an antibiotic will not be needed. Urgency is not an issue because this is an expected effect from the trauma of surgery. The physician does not need to be called.

A client with a chronic UTI is scheduled for a number of lab tests. The nurse would note that which test result best evaluates whther the kidneys are being adversely affected? A) Serum potassium 3.8 B) UA specific gravity 1.015 C) Serum creatinine 2.0 D) Urine culture negative

ANS: C

The nurse is assessing cognitive status on a client who ahd developed urinary incontinence. When questioned by the family, the nurse explains that this assessment will help to determine what condition? A) Stress incontinence B) Overflow incontinence C) Functional incontinence D) Mixed incontinence

ANS: C

The nurse is caring for a client with recurrent cystitis. Which instruction should be included prior to discharge? A) Limit fluid daily intake to decrease the urge to void. B) There is no relationship between sexual intercourse and cystitis C) Void at least q4h even if the urge is absent D) Daily cranberry juice has been proven to decrease the number of UTIs

ANS: C

The nurse is assessing a client who has undergone a transurethral resection of the prostate (TURP). Which assessment finding requires immediate action by the nurse? a. Passing small blood clots after catheter removal b. Experiencing urinary frequency after catheter removal c. Having bright red drainage with multiple blood clots d. Having the urge to void continuously while the catheter is inserted

ANS: C A client who undergoes a TURP is at risk for bleeding during the first 24 hours after surgery. Passage of small blood clots and tissue debris, urinary frequency and leakage, and the urge to void continuously while the client still has the catheter inserted are all considered to be expected complications of the procedure. They will resolve as the client continues to recover and the catheter is removed. However, the presence of bright red blood with clots indicates arterial bleeding and should be reported to the provider.

A client just underwent a keratoplasty. Which activity does the nurse suggest that the client begin possibly 1 week after surgery? a. Continue with salsa dance lessons. b. Jog only one-half mile versus the usual 2 miles. c. Return to employment as a receptionist. d. Help the family move furniture from room to room.

ANS: C Activities that raise the intraocular pressure (e.g., jogging, dancing, any movement that can cause jerky head motion) should be discouraged for at least 3 weeks after surgery. No heavy lifting should be done for 6 to 8 weeks. A sedentary job such as a receptionist can be tolerated a week after surgery.

A nurse should instruct a patient with recurrent staphylococcal and seborrheic blepharitis to a. irrigate the eyes with saline solution. b. apply cool compresses to the eyes three times daily. c. use a gentle baby shampoo to clean the lids as needed. d. schedule an appointment for surgical removal of the lesion.

ANS: C Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder.

Nursing staff on a hospital unit are reviewing rates of hospital-acquired infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for HAI in patients admitted to the hospital? a. Encouraging adequate oral fluid intake b. Testing urine with a dipstick daily for nitrites c. Avoiding unnecessary urinary catheterizations d. Providing frequent perineal hygiene to patients

ANS: C Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use. DIF: Cognitive Level: Analyze (analysis) REF: 1068 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A hospitalized patient with possible renal insufficiency after coronary artery bypass surgery is scheduled for a creatinine clearance test. Which equipment will the nurse need to obtain? a. Urinary catheter b. Cleaning towelettes c. Large container for urine d. Sterile urine specimen cup

ANS: C Because creatinine clearance testing involves a 24-hour urine specimen, the nurse should obtain a large container for the urine collection. Catheterization, cleaning of the perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this test. DIF: Cognitive Level: Apply (application) REF: 1056 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has undergone a left tympanoplasty should be instructed to a. remain on bed rest. b. keep the head elevated. c. avoid blowing the nose. d. irrigate the left ear canal.

ANS: C Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation

A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

ANS: C GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

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

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

A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? a. "I will apply the eardrops to the cotton wick in the ear canal." b. "I can use aspirin or acetaminophen (Tylenol) for pain relief." c. "I will clean the ear canal daily with a cotton-tipped applicator." d. "I can use warm compresses to the outside of the ear for comfort."

ANS: C Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful

A client is having intraocular pressure measured for both eyes. Which response by the client best indicates that the client understands why this is necessary every year? a. "Elevated eye pressure can cause high blood pressure." b. "If eye pressure is too high, your eyes will dry out." c. "Elevated eye pressure can press on blood vessels in the eye." d. "Increased eye pressure causes the tear ducts to become blocked."

ANS: C Intraocular pressure is the pressure generated by the fluids inside the globe of the eye. As intraocular pressure increases to above normal, it compresses the blood vessels and the optic nerves. As the blood vessels are compressed, oxygenation to the internal eye structures, including the nerves and photoreceptors, is diminished. The nerves and photoreceptors require a constant supply of oxygen and will die if blood flow is inadequate, leading to blindness. The other statements are inaccurate.

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? a. Atenolol (Tenormin) taken to prevent angina b. Acetaminophen (Tylenol) taken frequently for headaches c. Ibuprofen (Advil) taken for 20 years to treat osteoarthritis d. Albuterol (Proventil) taken since childhood to treat asthma

ANS: C Nonsteroidal antiinflammatory drugs (NSAIDs) are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

When a patient's urine dipstick test indicates a small amount of protein, the nurse's next action should be to a. send a urine specimen to the laboratory to test for ketones. b. obtain a clean-catch urine for culture and sensitivity testing. c. inquire about which medications the patient is currently taking. d. ask the patient about any family history of chronic renal failure.

ANS: C Normally the urinalysis will show zero to trace amounts of protein, but some medications may give false-positive readings. The other actions by the nurse may be appropriate, but checking for medications that may affect the dipstick accuracy should be done first. DIF: Cognitive Level: Apply (application) REF: 1057 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

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

Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)? a. Teach the patient about use of medications to reduce symptoms. b. Place the patient in a dark, quiet room to avoid stimulating BPPV attacks. c. Teach the patient that canalith repositioning may be used to reduce dizziness. d. Speak slowly and in a low-pitch to ensure that the patient is able to hear instructions.

ANS: C The Epley maneuver is used to reposition "ear rocks" in BPPV. Medications and placement in a dark room may be used to treat Ménière's disease, but are not necessary for BPPV. There is no hearing loss with BPPV

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

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

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

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

A patient with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of a. replacing fluid volume. b. preventing hypertension. c. maintaining cardiac output d. diluting nephrotoxic substances.

ANS: C The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

The nurse is caring for a young adult who just got married and has been diagnosed with testicular cancer. To which community resource does the nurse refer him? a. American Cancer Society b. Red Cross c. Sperm bank d. Public Health Department

ANS: C The young man with testicular cancer should be referred to a sperm bank, so that he will have the option to have children in the future if he so desires. The other resources listed will not provide assistance in this area. The American Cancer Society does offer several resources for clients with cancer and their families, but referral to a sperm bank would be the priority owing to the man's age and his newly married status.

The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease a. speaking slowly to the patient. b. facing the patient directly when speaking. c. encouraging the patient to ambulate independently. d. administering Rinne and Weber tests to the patient.

ANS: C Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.

A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? a. Suggest the patient arrange a ride to the clinic immediately. b. Ask about the presence of "floaters" in the patient's visual field. c. Remind the patient it may take months to restore vision after transplant. d. Teach the patient to continue using prescribed pupil-dilating medications.

ANS: C Vision may not be restored for up to a year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because "floaters" are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant surgery

A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's a. blood glucose. b. urine osmolality. c. serum creatinine. d. serum potassium.

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

A client with acute-angle glaucoma has several medications ordered. Which medications does the nurse question? (Select all that apply.) a. Acetazolamide (Diamox) b. Pilocarpine (Pilocar) c. Atropine (Isopto Atropine) d. Latanoprost (Xalatan) e. Timolol (Timoptic) f. Epinephrine

ANS: C, F Atropine and epinephrine are mydriatics, which decrease the outflow of aqueous humor, resulting in increased intraocular pressure (IOP). Diamox is a carbonic anhydrase inhibitor that decreases the formation of aqueous humor. Pilocar is a miotic that enhances outflow of aqueous humor. Xalatan is a prostaglandin agonist that improves outflow, and Timoptic is a beta blocker that decreases the formation of aqueous humor. All these help decrease IOP.

Which statement by the patient to the home health nurse indicates a need for more teaching about self-administering eardrops? a. "I will leave the ear wick in place while administering the drops." b. "I should lie down before and for 5 minutes after administering the drops." c. "I will hold the tip of the dropper above the ear while administering the drops." d. "I should keep the medication refrigerated until I am ready to administer the drops."

ANS: D Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate.

The nurse in the eye clinic is examining a 67-year-old patient who says "I see small spots that move around in front of my eyes." Which action will the nurse take first? a. Immediately have the ophthalmologist evaluate the patient. b. Explain that spots and "floaters" are a normal part of aging. c. Inform the patient that these spots may indicate retinal damage. d. Use an ophthalmoscope to examine the posterior eye chambers.

ANS: D Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

The health care provider prescribes the following interventions for a patient with acute prostatitis caused by Escherichia coli. Which intervention should the nurse question? a. Give trimethoprim/sulfamethoxazole 1 tablet daily for 28 days. b. Administer ibuprofen 400 mg every 8 hours as needed for pain. c. Instruct patient to avoid sexual intercourse until treatment is complete. d. Catheterize the patient as needed if symptoms of urinary retention develop.

ANS: D Although acute urinary retention may occur, insertion of a catheter through an inflamed urethra is contraindicated, and the nurse will anticipate that the health care provider will need to insert a suprapubic catheter. The other actions are appropriate. DIF: Cognitive Level: Apply (application) REF: 1282 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective? a. The patient denies pain with voiding. b. The urine dipstick is negative for nitrites. c. The antistreptolysin-O (ASO) titer is decreased. d. The periorbital and peripheral edema is resolved.

ANS: D Because edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Nitrites will be negative and the patient will not experience dysuria because the patient does not have a urinary tract infection. Antibodies to streptococcus will persist after a streptococcal infection. DIF: Cognitive Level: Apply (application) REF: 1074 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

When obtaining a focused health history for a patient with possible testicular cancer, the nurse will ask the patient about any history of a. sexually transmitted disease (STD) infection. b. testicular trauma. c. testicular torsion. d. undescended testicles.

ANS: D Cryptorchidism is a risk factor for testicular cancer if it is not corrected before puberty. STD infection, testicular torsion, and testicular trauma are risk factors for other testicular conditions but not for testicular cancer.

To assess whether there is any improvement in a patient's dysuria, which question will the nurse ask? a. "Do you have to urinate at night?" b. "Do you have blood in your urine?" c. "Do you have to urinate frequently?" d. "Do you have pain when you urinate?"

ANS: D Dysuria is painful urination. The alternate responses are used to assess other urinary tract symptoms: hematuria, nocturia, and frequency. DIF: Cognitive Level: Apply (application) REF: 1056 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological

A 32-year-old patient who is employed as a hairdresser and has a 15 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for a. renal failure. b. kidney stones. c. pyelonephritis. d. bladder cancer.

ANS: D Exposure to the chemicals involved with working as a hairdresser and in smoking both increase the risk of bladder cancer, and the nurse should assess whether the patient understands this risk. The patient is not at increased risk for renal failure, pyelonephritis, or kidney stones. DIF: Cognitive Level: Apply (application) REF: 1053 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

A 68-year-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care? a. Restrict fluids between meals and after the evening meal. b. Apply absorbent incontinent pads liberally over the bed linens. c. Insert an indwelling catheter until the symptoms have resolved. d. Assist the patient to the bathroom every 2 hours during the day.

ANS: D In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration. DIF: Cognitive Level: Apply (application) REF: 1089 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 55-year-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan? a. Assist the patient to the bathroom q3hr. b. Place a commode at the patient's bedside. c. Demonstrate how to perform the Credé maneuver. d. Teach the patient how to perform Kegel exercises.

ANS: D Kegel exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence. DIF: Cognitive Level: Apply (application) REF: 1089 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen? a. As close to the client's face as possible b. As far away as possible, with low lights c. Directly in front of the client d. On either side of the client

ANS: D Macular degeneration decreases central vision but usually does not affect peripheral vision. Clients looking straight ahead can see people and objects off to the side. Therefore the television should be placed on either side of the client. The other options would not help the client with macular degeneration to see the screen.

Which assessment data reported by a 28-year-old male patient is consistent with a lower urinary tract infection (UTI)? a. Poor urine output b. Bilateral flank pain c. Nausea and vomiting d. Burning on urination

ANS: D Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI. DIF: Cognitive Level: Apply (application) REF: 1066 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medications should the nurse question? a. Morphine sulfate 4 mg IV b. Diazepam (Valium) 5 mg IV c. Betaxolol (Betoptic) 0.25% eyedrops d. Scopolamine patch (Transderm Scop) 1.5 mg

ANS: D Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient

The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medications should the nurse question? a. Morphine sulfate 4 mg IV b. Diazepam (Valium) 5 mg IV c. Betaxolol (Betoptic) 0.25% eyedrops d. Scopolamine patch (Transderm Scop) 1.5 mg

ANS: D Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient.

A client has just returned from having surgery, and sulfahexafluoride gas was used intraocularly. How does the nurse position the client? a. Completely supine, with sandbags beside the head b. On the nonoperative side in the Trendelenburg position c. On the operative side in the Trendelenburg position d. On the abdomen, with the affected eye up

ANS: D Sulfahexafluoride gas has a lower specific gravity than the vitreous humor. It will float to the highest position. The client should be positioned so that the gas will float up and against the newly reattached retina. The other positions are incorrect after this procedure.

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH) the nurse will ask the patient about a. blood in the urine. b. lower back or hip pain. c. erectile dysfunction (ED). d. strength of the urinary stream.

ANS: D The American Urological Association (AUA) Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and back or hip pain are not typical symptoms of BPH.

Which statement indicates that a client understands why his cataract surgery is being done first on the eye with the poorest vision? a. "Insurance reimbursement dictates the timing of surgeries." b. "The eye with poorer vision is at greater risk for permanent damage." c. "The pressure in the poorer eye could increase, causing permanent damage." d. "If a complication arises in that eye, I will still have some vision in the better eye."

ANS: D The eye with the better sight is left alone until the outcome of the first surgery is known to reduce the chance that the client will lose sight in both eyes if complications arise from the surgery.

Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? a. The patient complains of a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of "a curtain" over part of the visual field.

ANS: D The patient's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient's history of being hit in the eye.

A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will need to use bright lights to read for at least the next week." b. "I will use drops to keep my pupils dilated until my appointment." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will cover up with long-sleeved shirts and pants for the next 5 days."

ANS: D The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment.

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-year-old female patient with cystitis when the patient states which of the following? a. "I can use vaginal antiseptic sprays to reduce bacteria." b. "I will drink a quart of water or other fluids every day." c. "I will wash with soap and water before sexual intercourse." d. "I will empty my bladder every 3 to 4 hours during the day."

ANS: D Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI. DIF: Cognitive Level: Apply (application) REF: 1069 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance

When assisting a blind patient in ambulating to the bathroom, the nurse should a. take the patient by the arm and lead the patient slowly to the bathroom. b. have the patient place a hand on the nurse's shoulder and guide the patient. c. stay beside the patient and describe any obstacles on the path to the bathroom. d. walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.

ANS: D When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient

Which of the following signs and symptoms would the nurse expect to see in the elderly patient with a UTI? A) Back pain B) High Fever C) ALOC D) Anorexia E) Tachypnea

Answer: C, D, and E. In elderly patients, the nurse would expect to see more nonspecific signs of urinary tract infection including changes in level of consciousness, lethargy, anorexia, new incontinences, hyperventilation, and low-grade fever. Back pain may be present with UTI, but is not common in elderly patients. High fever is typically not present.

The nurse is teaching the patient who has just been given a urinary diversion (ileal conduit). Which of the following statements, if made by the patient, indicates the need for further teaching? A) I should not expect to feel pain at the stoma B) The stoma could bleed when I clean it C) I should report any signs of mucous in the urine to my doctor D) The stoma should be pink and moist

Answer: C. Because a segment of the GI system is typically used to create a urinary diversion, mucous would be expected in the urine. The stoma is vascular, and could bleed when cleaned. There are no nerve endings at the stoma, so there should be no pain. The stoma should be pink and moist like the inside of the mouth.

11. When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as a. administering sedatives to promote rest and decrease myocardial oxygen demand. b. positioning the patient in a high-Fowler's position with the feet horizontal in the bed. c. administering oxygen per mask or nasal cannula. d. encouraging leg exercises to improve venous return.

B Rationale: Positioning the patient in a high-Fowler's position with the legs dependent will reduce preload by decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart failure but will not help in decreasing preload. Cognitive Level: Application Text Reference: pp. 827-828 Nursing Process: Planning NCLEX: Physiological Integrity

After receiving change-of-shift report, which of these patients admitted with heart failure should the nurse assess first? a. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure (BP) of 100/56 b. A patient who is cool and clammy, with new-onset confusion and restlessness c. A patient who had dizziness after receiving the first dose of captopril (Capoten) d. A patient who has crackles in both posterior lung bases and is receiving oxygen

B The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible, but do not have indications of severe decreases in tissue perfusion.

A nurse provides health screening for a community health center with a large population of African-American clients. Which priority assessment should the nurse include when working with this population? a. Measure height and weight. b. Assess blood pressure. c. Observe for any signs of abuse. d. Ask about medications.

B ~ All interventions are important for the visiting nurse to accomplish. However, African Americans have a high rate of hypertension leading to end-stage renal disease. Each encounter that the nurse has with an African-American client provides a chance to detect hypertension and treat it. If the client is already on antihypertensive medication, assessing blood pressure monitors therapy.

The health care provider prescribes these orders. Which will you implement first? A. Decrease IV fluids from 100 mL to 50 mL/hr. B. Administer calcium chloride (Kalcinate) 1000 mg IV. C. Give sodium polystyrene sulfonate (Kayexalate) 15 g. D. Notify the dialysis department to prepare for continuous renal replacement therapy (CCRT)

B ~ Calcium chloride administration will rapidly shift potassium from the extracellular to the intracellular space and correct the patient's bradycardia and QRS widening. This effect only lasts about 30 to 60 minutes, so the nurse will also need to administer Kayexalate, which will work over the next few hours to bind potassium in the gut and lower the total body potassium level. The patient's laboratory and assessment information indicates that decreasing fluid intake and hemodialysis or CCRT are also appropriate, but the nurse's first action should be to correct potentially fatal dysrhythmias caused by the hyperkalem

An emergency department nurse assesses a client with kidney trauma and notes that the client's abdomen is tender and distended and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation? a. Assessing vital signs every 15 minutes b. Inserting an indwelling urinary catheter c. Administering intravenous fluids at 125 mL/hr d. Typing and crossmatching for blood products

B ~ Clients with blood at the urinary meatus should not have a urinary catheter inserted via the urethra before additional diagnostic studies are done. The urethra could be torn. The nurse should question the provider about the need for a catheter; if one is needed, the provider can insert a suprapubic catheter. The nurse should monitor the client's vital signs closely, send blood for type and crossmatch in case the client needs blood products, and administer intravenous fluids.

After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? a. I must decrease my intake of fat. b. I will increase my intake of protein. c. A decreased intake of carbohydrates will be required. d. An increased intake of vitamin C is necessary.

B ~ In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder.

After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will take this medication with food and plenty of water. b. I shall keep my appointment at the infusion center each week. c. I'll limit my intake of green leafy vegetables while on this medication. d. I must not take this medication if I have an infection or am feeling ill.

B ~ emsirolimus is administered as a weekly intravenous infusion. This medication blocks protein that is needed for cell division and therefore inhibits cell cycle progression. This medication is not taken orally, and clients do not need to follow a specific diet.

A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. What should this patient be taught to avoid? A. High-potassium foods B. Drugs to treat erectile dysfunction C. Nonsteroidal antiinflammatory drugs D. Over-the-counter H2-receptor blockers

B. Drugs to treat erectile dysfunction The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. High-potassium foods, NSAIDs, and H2-receptor blockers do not pose a risk in combination with nitrates.

What should the nurse recognize as an indication for the use of dopamine (Intropin) in the care of a patient with heart failure? A. Acute anxiety B. Hypotension and tachycardia C. Peripheral edema and weight gain D. Paroxysmal nocturnal dyspnea (PND)

B. Hypotension and tachycardia Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.

A patient with chronic kidney disease (CKD) brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required? a. multivitamin with iron b. Milk of magnesia 30 mL c. calcium phosphate d. tylenol 650 mg

B. Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.

A patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first? a. obtain renal ultrasound b. Insert retention catheter. c. infuse normal saline at 50 ml/hr d. draw blood for CBC

B. The patient's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate, but should be implemented after the retention catheter.

The nurse is admitting a client to the coronary care unit​ (CCU) and is assessing risk factors for heart failure. What is the most concerning risk​ factor? Body mass index​ (BMI) of 18.0 Influenza Blood pressure of​ 188/122 mm/Hg Total cholesterol of 184​ mg/dL

Blood pressure of​ 188/122 mm/Hg

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum creatine kinase (CK) b. Arterial blood gases (ABGs) c. B-type natriuretic peptide (BNP) d. 12-lead electrocardiogram (ECG)

C BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK also may be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

3. During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. incompetent jugular vein valves. c. elevated right atrial pressure. d. jugular vein atherosclerosis.

C Rationale: The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume; it is not caused by incompetent jugular vein valves or atherosclerosis. Cognitive Level: Comprehension Text Reference: p. 825 Nursing Process: Assessment NCLEX: Physiological Integrity

Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the nitroprusside rate if the patient develops a. a dry, hacking cough. b. any ventricular ectopy. c. a systolic BP <90 mm Hg. d. a heart rate <50 beats/minute.

C Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy

A patient with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's first action will be to a. ask the patient to recall the dietary intake for the last 3 days. b. question the patient about the use of the prescribed medications. c. assess the patient for clinical manifestations of acute heart failure. d. teach the patient about the importance of dietary sodium restrictions.

C The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

An outpatient who has heart failure returns to the clinic after 2 weeks of therapy with carvedilol (Coreg). Which of these assessment findings is most important for the nurse to report to the health care provider? a. Pulse rate of 56 b. 2+ pedal edema c. BP of 88/42 mm Hg d. Complaints of fatigue

C The patient's BP indicates that the dose of carvedilol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of -adrenergic blockade, but the rate of 56 is not unusual with -blocker therapy. -adrenergic blockade initially will worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

A nurse cares for a client who has pyelonephritis. The client states, "I am embarrassed to talk about my symptoms." How should the nurse respond? a. I am a professional. Your symptoms will be kept in confidence. b. I understand. Elimination is a private topic and shouldn't be discussed. c. Take your time. It is okay to use words that are familiar to you. d. You seem anxious. Would you like a nurse of the same gender to care for you?

C ~ Clients may be uncomfortable discussing issues related to elimination and the genitourinary area. The nurse should encourage the client to use language that is familiar to the client. The nurse should not make promises that cannot be kept, like keeping the client's symptoms confidential. The nurse must assess the client and cannot take the time to stop the discussion or find another nurse to complete the assessment.

A 36 year old female, who is 29 weeks pregnant, reports she is experiencing burning when voiding. The physician orders a urinalysis. Which statement by the patient demonstrates she understands how to collect the specimen? A. "I'll hold the cup firmly against the urethra while collecting the sample." B. "I will cleanse back to front with the antiseptic wipe before peeing in the cup." C. "First, I will pee a small amount of urine in the toilet and then collect the rest in the cup." D. "I will be sure to drink a lot of fluids to keep the urine diluted before peeing into the cup."

C. "First, I will pee a small amount of urine in the toilet and then collect the rest in the cup."

What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? A. Urine output B. Lung sounds C. Blood pressure D. Respiratory rate

C. Blood pressure Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.

The physician orders a urine culture on your patient in room 5505 with a urinary tract infection. In addition, the patient is ordered to start IV Bactrim (Sulfamethoxazole/Trimethoprim). How will you proceed with following this order? A. First, hang the antibiotic, and then collect the urine culture. B. First, hang the antibiotic and when the antibiotic is finished infusing collect the urine culture. C. First, collect the urine culture, and then hang the antibiotic. D. First, collect the urine culture and then hold the dose of the antibiotic until the urine culture is back from the lab.

C. First, collect the urine culture, and then hang the antibiotic.

Which parameter will be most important for the nurse to consider when titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation? a. HR b. BUN c. Urine output d. Creatinine

C. Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first? a. slow rate of dialysis b. Obtain blood to check BUN c. Check the patient's blood pressure. d. give prescribed PRN antiemetic drug

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

When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis b. unlimited fluids are allowed since retained fluid is removed during dialysis c. More protein will be allowed because of the removal of urea and creatinine by dialysis. d. dietary sodium and potassium are unrestricted because these levels are normalized by dialysis

COnce the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

A client recently admitted to the coronary care unit​ (CCU) with left heart failure complains of sudden​ dyspnea, anxiety, and feelings of​ "drowning." What is the most likely cause of these​ changes? Myocardial infarction Cardiogenic pulmonary edema Hyperglycemia Pulmonary embolism

Cardiogenic pulmonary edema

When taking a nursing history from a patient with BPH, the nurse would expect the patient to report a. nocturia, dysuria, and bladder spasms. b. urinary frequency, hematuria, and perineal pain. c. urinary hesitancy, postvoid dribbling, and weak urinary stream. d. urinary urgency with a forceful urinary stream and cloudy urine.

Correct Answer: C Rationale: Classic symptoms of uncomplicated BPH are those associated with urinary obstruction and include diminished caliber and force of the urinary stream, hesitancy, difficulty initiating voiding, intermittent urination, dribbling at the end of urination, and a feeling of incomplete bladder emptying because of urinary retention. Irritative symptoms, including nocturia, frequency, dysuria, urgency, or hematuria, occur if infection results from urinary retention.

A hemodialysis client has a newly created left arm fistula. The nurse monitors the affected extremity for which signs and symptoms that indicate a complication related to steal syndrome? a) edema and purplish discoloration b) aching pain, pallor, and edema c) warmth, redness, and pain d) pallor, diminished pulse. and pain

D - Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula from tissue ischemia. Warmth, redness, and pain would more likely characterize a problem with infection. The patterns described in options A and B are not usually observed because they do not relate to a complication following fistula creation.

Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 38%? a. Need to participate in an aerobic exercise program several times weekly b. Use of salt substitutes to replace table salt when cooking and at the table c. Importance of making a yearly appointment with the primary care provider d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

D The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.

A nurse cares for a client with autosomal dominant polycystic kidney disease (ADPKD). The client asks, "Will my children develop this disease?" How should the nurse respond? a. No genetic link is known, so your children are not at increased risk. b. Your sons will develop this disease because it has a sex-linked gene. c. Only if both you and your spouse are carriers of this disease. d. Each of your children has a 50% risk of having ADPKD.

D ~ Children whose parent has the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease. ADPKD is transmitted as an autosomal dominant trait and therefore is not gender specific. Both parents do not need to have this disorder.

A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take? a. Document the finding in the client's record. b. Evaluate the tube as working in the hand-off report. c. Clamp the tube in preparation for removing it. d. Assess the client's abdomen and vital signs.

D ~ The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should carefully assess the client's abdomen for pain and distention and check vital signs so that this information can be reported as well. The other interventions are not appropriate.

A client has undergone creation of an ileal conduit. Which instruction to the client about urostomy care would be appropriate to include in the teaching plan? A) Cut the faceplate of the appliance so that the opening is slightly smaller than the stoma B) Plan to do appliance changes just before bedtime C) Limit fluids to minimize odor from urine breakdown to ammonia D) Cleanse the skin around the stoma using gentle soap and water, rinse and dry well

D) Cleanse the skin around the stoma using gentle soap and water, rinse and dry well

You're providing discharge teaching to a female patient on how to prevent urinary tract infections. Which statement is INCORRECT? A. "Void immediately after sexual intercourse." B. "Avoid wearing tight fitting underwear." C. "Try to void every 2-3 hours." D. "Use scented sanitary napkins or tampons during menstruation."

D. "Use scented sanitary napkins or tampons during menstruation."

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? A. Muscle aches B. Constipation C. Pounding headache D. Anorexia and nausea

D. Anorexia and nausea Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? A. Nocturia B. Scrotal edema C. Occasional constipation D. Decreased force in the stream of urine

D. Decreased force in the stream of urine

A patient complains of leg cramps during hemodialysis. The nurse should first a. reposition pt b. massage pt legs c. give tylenol d. infuse a bolus of normal saline.

D. Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

A patient, who is having spasms and burning while urinating due to a UTI, is prescribed "Pyridium" (Phenazopyridine). Which option below is a normal side effect of this drug? A. Hematuria B. Crystalluria C. Urethra mucous D. Orange colored urine

D. Orange colored urine

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

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

After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? A. ADHF B. Chronic HF C. Left-sided HF D. Right-sided HF

D. Right-sided HF An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.

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

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

What is the normal lab value for Urine Nitrates?

ZERO

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. High-risk patients include those exposed to nephrotoxic agents and advanced age (a), massive trauma (b), prolonged hypovolemia or hypotension (possibly b and c), obstetric complications (c), cardiac failure (d), preexisting chronic kidney disease, extensive burns, or sepsis. Patients with prostate cancer may have obstruction of the outflow tract, which increases risk of postrenal AKI (e).

The patient with CKD is receiving dialysis, and the nurse observes excoriations on the patient's skin. What pathophysiologic changes in CKD can contribute to this finding (select all that apply)? a. Dry skin b. Sensory neuropathy c. Vascular calcifications d. Calcium-phosphate skin deposits e. Uremic crystallization from high BUN

a, b, d. Pruritus is common in patients receiving dialysis. It causes scratching from dry skin, sensory neuropathy, and calcium-phosphate deposition in the skin. Vascular calcifications contribute to cardiovascular disease, not to itching skin. Uremic frost rarely occurs without BUN levels greater than 200 mg/dL, which should not occur in a patient on dialysis; urea crystallizes on the skin and also causes pruritis.

Number the following in the order of the phases of exchange in PD. Begin with 1 and end with 3. a. Drain b. Dwell c. Inflow

a. 3; b. 2; c. 1

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

a. Erythropoietin is used to treat anemia, as it stimulates the bone marrow to produce red blood cells.

A patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks being experienced. What should the nurse include in the discharge teaching for this patient? a. Airplane travel will be more comfortable now. b. Avoid sudden head movements or position changes. c. Cough or blow the nose to keep the Eustachian tubes clear. d. Take antihistamines, antiemetics, and sedatives for recovery.

b. Avoid sudden head movements or position changes. After ear surgery, the patient should avoid sudden head movements or position changes. The patient should not cough or blow the nose because this increases pressure in the Eustachian tube and middle ear cavity and may disrupt healing. Airplane travel should be avoided at first as increased pressure and ear popping is normally experienced, which will disrupt healing. Antihistamines, antiemetics, and sedatives are used to decrease the symptoms of acute attacks of Ménière's disease.

What is the most serious electrolyte disorder associated with kidney disease? a. Hypocalcemia b. Hyperkalemia c. Hyponatremia d. Hypermagnesemia

b. Hyperkalemia can lead to life-threatening dysrhythmias. Hypocalcemia leads to an accelerated rate of bone remodeling and potentially to tetany. Hyponatremia may lead to confusion. Elevated sodium levels lead to edema, hypertension, and heart failure. Hypermagnesemia may decrease reflexes, mental status, and blood pressure.

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. Nifedipine (Procardia) is a calcium channel blocker and furosemide (Lasix) is a loop diuretic. Both are used to treat hypertension.

In replying to a patient's questions about the seriousness of her chronic kidney disease (CKD), the nurse knows that the stage of CKD is based on what? a. Total daily urine output b. Glomerular filtration rate c. Degree of altered mental status d. Serum creatinine and urea levels

b. Stages of chronic kidney disease are based on the GFR. No specific markers of urinary output, mental status, or azotemia classify the degree of chronic kidney disease (CKD).

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. Hyperkalemia is a potentially life-threatening complication of AKI in the oliguric phase. Muscle weakness and abdominal cramping are signs of the neuromuscular impairment that occurs with hyperkalemia. In addition, hyperkalemia can cause the cardiac conduction abnormalities of peaked T wave, prolonged PR interval, prolonged QRS interval, and depressed ST segment. Urine output of 300 mL/day is expected during the oliguric phase, as is the development of peripheral edema.

When administering a scheduled dose of pilocarpine, in which area should the nurse place the drops? a. Inner canthus b. Outer canthus c. Center of the eyeball d. Lower conjunctival sac

d. Lower conjunctival sac Ocular medications such as pilocarpine should be instilled into the lower conjunctival sac. Never apply eye drops directly to the cornea. Applying the drops to the inner canthus will cause them to be distributed systemically.

A nurse is implementing comfort measures for a client with class IV heart failure. What position is best for client​ comfort? Left lateral Supine Prone ​High-Fowler

​High-Fowler

The nurse is caring for a patient with orchitis. What treatment should the nurse anticipate educating this patient regarding? Select all that apply. 1. Exercising 2. Analgesic medication 3. Maintaining a usual routine 4. Antibiotic treatment if organism is known 5. Bed rest with scrotum elevated on ice pack

2. Analgesic medication 4. Antibiotic treatment if organism is known 5. Bed rest with scrotum elevated on ice pack

The nurse is providing care to a patient with a new diagnosis of benign prostatic hyperplasia. Which medication does the nurse anticipate educating the patient about that will facilitate urinary flow through the urethra by bringing about smooth muscle relaxation? 1. Tadalafil 2. Doxazosin 3. Dutasteride 4. Rye-grass pollen extract

2. Doxazosin

The nurse is educating a patient about the treatment of prostate cancer to decrease the prostate specific antigen (PSA) levels. Which medication will the nurse discuss with the patient? 1. Acetonide 2. Finasteride 3. Alprostadil 4. Papaverine

2. Finasteride

A male patient reports nocturia, pain in the suprapubic area, incontinence, and urinary frequency and is found to have bacteria and white blood cells in the urine. What does the nurse determine predisposing factors are in this patient? Select all that apply. 1. Orchitis 2. Obesity 3. Hypertension 4. Atherosclerosis 5. Erectile dysfunction

2. Obesity 5. Erectile dysfunction

The nurse is educating a patient regarding the treatment of erectile dysfunction (ED). What should the nurse be sure to include when discussing this with the patient? Select all that apply. 1. Side effects like constipation and weight loss can occur. 2. Side effects like headache, dyspepsia, and flushing can occur. 3. Rare side effects like confusion and redness of eyes can occur. 4. Rare side effects like visual disturbances and hearing loss can occur. 5. Patients should immediately seek medical attention in case of priapism.

2. Side effects like headache, dyspepsia, and flushing can occur. 4. Rare side effects like visual disturbances and hearing loss can occur. 5. Patients should immediately seek medical attention in case of priapism.

A patient had an abnormal digital rectal exam (DRE) followed by an elevated prostate specific antigen (PSA). For what diagnostic study will the nurse prepare the patient after receiving these results? 1. Cystoscopy 2. Uroflowmetry 3. Transrectal ultrasound (TRUS) 4. Magnetic resonance imaging (MRI)

3. Transrectal ultrasound (TRUS)

What is the normal lab value for urine pH?

4.8-7.5

What is the normal lab value for Urine Sodium?

40-220 mEq/day

A client with renal malignancy is admitted to the hospital for a diagnostic workup and probable surgery. During the admission assessment the nurse inquires about the presence of which common symptom related to this problem? a) flank pain and intermittent hematuria b) suprapubic pain and constant slight hematuria c) flank pain and foul-smelling urine d) abdominal pain and decreased urine output

A - Renal cancer is commonly manifested by hematuria and flank pain (not abdominal or suprapubic), and a palpable mass may be palpated on physical examination. Because the hematuria is gross but intermittent, the client may delay seeking medical treatment. Foul-smelling urine could indicate infection. Decreased urine output could indicate renal insufficiency.

During a visit to a 72-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain, and complains of "feeling too tired to do anything." Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to fatigue. b. disturbed body image related to leg swelling. c. impaired skin integrity related to peripheral edema. d. impaired gas exchange related to chronic heart failure.

A The patient's statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems.

Which patient is most likely to receive a diagnosis of heart failure? A 34-year-old woman who is 3 weeks postpartum and is being seen by the healthcare provider for follow-up on the preeclampsia she experienced while pregnant A 3-year-old who presents with a stage II pulmonary heart murmur, whose mother reported that she had preeclampsia while pregnant with the child A 62-year-old who has been working with a nutritionist for the past 5 years to help lose weight and keep type 2 diabetes under control A 75-year-old smoker with a history of hypertension and anxiety who retired 5 years ago after a long career in law enforcement

A 75-year-old smoker with a history of hypertension and anxiety who retired 5 years ago after a long career in law enforcement

A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)? A. Administer ordered morphine sulfate. B. Position patient in a semi-Fowler's position. C. Position patient on left side with head of bed flat. D. Instruct patient on the use of relaxation techniques. E. Use a calm, reassuring approach while talking to patient.

A, B, D, E. Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.

A 76 year old female is admitted due to a recent fall. The patient is confused and agitated. The family members report that this is not normal behavior for the patient. They explain that the patient is very active in the community and cares for herself. Based on the information you have gathered about the patient, which physician's order takes priority? A. "Collect a urinalysis" B. "Collect a T3 and T4 level" C. "Insert a Foley Catheter" D. "Keep patient NPO"

A. "Collect a urinalysis"

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

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

A renal failure patient undergoing peritoneal dialysis who has kidney disease due to diabetes mellitus. After placing 1200 ml of dialysate, only 400 ml has drained. What should you do next? A. Check the catheter for obstruction B. Place the patient on his left side C. Instill 500 ml of dialysate D. Clamp the catheter and palpate the abdomen

A. Check the catheter for obstruction

Which of the following symptoms and/or conditions are associated with disequilibrium syndrome related to a patient with chronic kidney disease beginning his first hemodialysis treatment? A. Headache, vomiting, and restlessness B. Fever and weakness C. Pulmonary edema and difficulty breathing D. Peritonitis, tachycardia, and decreased blood pressure

A. Headache, vomiting, and restlessness

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? A. Palpation of a thrill over the fistula B. Presence of a radial pulse in the left wrist C. Visualization of enlarged blood vessels on the fistula site D. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

A. Palpation of a thrill over the fistula

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? A. Reduce preload. B. Decrease afterload. C. Increase contractility. D. Promote vasodilation.

A. Reduce preload. Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.

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

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

During a head-to-toe assessment on a patient with a possible urinary tract infection, you perform costovertebral angle percussion. The costovertebral angle is found? A. between the bottom of the 12th rib and spine B. between the right upper quadrant and umbilicus C. between the sternal notch and angle of Louis D. between the ischial spine and umbilicus

A. between the bottom of the 12th rib and spine

A client is admitted to the E.D. with suspected urolithiasis. The nurse questions the client about the presence of which symptom that would be expected with urolithiasis? A) Flank pain B) Difficult urination C) Absence of urine D) Headache

ANS: A

When performing discharge teaching for a patient after a vasectomy, the nurse instructs the patient that he a. should continue to use other methods of birth control for 6 weeks. b. should not have sexual intercourse until his 6-week follow-up visit. c. may have temporary erectile dysfunction (ED) because of swelling. d. will notice a decrease in the appearance and volume of his ejaculate.

ANS: A Because it takes about 6 weeks to evacuate sperm that are distal to the vasectomy site, the patient should use contraception for 6 weeks. ED that occurs after vasectomy is psychologic in origin and not related to postoperative swelling. The patient does not need to abstain from intercourse. The appearance and volume of the ejaculate are not changed because sperm are a minor component of the ejaculate. DIF: Cognitive Level: Understand (comprehension) REF: 1286 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse should report which assessment finding immediately to the health care provider? a. The tympanum is blue-tinged. b. There is a cone of light visible. c. Cerumen is present in the auditory canal. d. The skin in the ear canal is dry and scaly.

ANS: A A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.

A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? a. A fistula is much less likely to clot. b. A fistula increases patient mobility. c. A fistula can accommodate larger needles. d. A fistula can be used sooner after surgery.

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

During the preoperative assessment of the patient scheduled for a right cataract extraction and intraocular lens implantation, it is most important for the nurse to assess a. the visual acuity of the patient's left eye. b. how long the patient has had the cataract. c. for a white pupil in the patient's right eye. d. for a history of reactions to general anesthetics.

ANS: A Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not affect the perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics

The nurse is caring for a patient who has had an ileal conduit for several years. Which nursing action could be delegated to unlicensed assistive personnel (UAP)? a. Change the ostomy appliance. b. Choose the appropriate ostomy bag. c. Monitor the appearance of the stoma. d. Assess for possible urinary tract infection (UTI).

ANS: A Changing the ostomy appliance for a stable patient could be done by UAP. Assessments of the site, choosing the appropriate ostomy bag, and assessing for (UTI) symptoms require more education and scope of practice and should be done by the registered nurse (RN).

Which is the most important information for the nurse to teach a client who is receiving cycloplegic drug therapy? a. "Do not drive or operate machinery until the drug wears off." b. "Use at least a 30 SPF sunscreen agent when going outdoors." c. "Remain on bedrest for 24 hours in a prone position." d. "Turn up the lights because acuity will be decreased in low-light environments."

ANS: A Cycloplegic agents prevent accommodation of the iris, resulting in a widely dilated pupil. The pupil cannot accommodate to bright light, causing eye discomfort and pain. Turning up the lights will not assist the client to see more clearly. Bedrest and sunscreen are not measures needed for this drug.

Which information will the nurse include for a patient contemplating a cochlear implant? a. Cochlear implants require training in order to receive the full benefit. b. Cochlear implants are not useful for patients with congenital deafness. c. Cochlear implants are most helpful as an early intervention for presbycusis. d. Cochlear implants improve hearing in patients with conductive hearing loss.

ANS: A Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness

The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first? a. 71-year-old who has noticed increasing loss of peripheral vision b. 74-year-old who has difficulty seeing well enough to drive at night c. 60-year-old who has difficulty hearing clearly in a noisy environment d. 64-year-old who has decreased hearing and ear "stuffiness" without pain

ANS: A Increasing loss of peripheral vision is characteristic of glaucoma and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbycusis, possible cerumen impaction, and impaired night vision.

The health care provider prescribes Flomax for a 56-year-old patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that a. he should change position from lying to standing slowly to avoid dizziness. b. his interest in sexual activity may decrease while he is taking the medication. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

ANS: A Orthostatic hypotension may occur if the patient is prescribed Flomax, putting them at risk for fallsalso is taking a medication for erectile dysfunction (ED), it should not occur with finasteride alone. Improvement in symptoms of obstruction takes about 6 months. The medication does not cause hypertension, if the patient was on Proscar then interest in sexual activity may decrease

A 44-year-old patient is unable to void after having an open loop resection and fulguration of the bladder. Which nursing action should be implemented first? a. Assist the patient to soak in a 15-minute sitz bath. b. Insert a straight urethral catheter and drain the bladder. c. Encourage the patient to drink several glasses of water. d. Teach the patient how to do isometric perineal exercises.

ANS: A Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids and Kegel exercises are helpful in the prevention of incontinence, these activities would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection (UTI) and should be avoided when possible

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). d. level of consciousness (LOC).

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

The nurse asks a patient with heart failure about diet, level of activity (tolerance, dyspnea with exertion), episodes of paroxysmal nocturnal dyspnea, and recent weight gain or loss. The nurse also reviews current medications. Which question should the nurse ask to reveal relevant data not collected? "Do you live with anyone at home?" "Does your abdomen feel tender or firm when you push on it?" "What do you do for a living?" "Do you have a history of hypertension?"

"Do you have a history of hypertension?"

The home care nurse visits a 34-year-old woman receiving peritoneal dialysis. Which statement, if made by the patient, indicates a need for immediate follow-up by the nurse? A. "Drain time is faster if I rub my abdomen." B."The fluid draining from the catheter is cloudy." C."The drainage is bloody when I have my period." D."I wash around the catheter with soap and water."

"The fluid draining from the catheter is cloudy." The primary clinical manifestation of peritonitis is a cloudy peritoneal effluent. Blood may be present in the effluent of women who are menstruating, and no intervention is indicated. Daily catheter care may include washing around the catheter with soap and water. Drain time may be facilitated by gently massaging the abdomen.

A patient is experiencing hot flashes, loss of libido, gynecomastia, and erectile dysfunction. What androgen deprivation therapy medication should the nurse educate the patient about? 1. Goserelin 2. Sildenafil 3. Degarelix 4. Abiraterone

1. Goserelin

A patient is taking several medications and informs the nurse of having dyspepsia, flushing, nasal congestion, and erections lasting more than four hours. Which medication does the nurse recognize may be the cause of these side effects? 1. Sildenafil 2. Cypionate 3. Enanthate 4. Alprostadil

1. Sildenafil

A male patient is infertile after having mumps as a child. Which disorder should the nurse inform the patient might occur related to the infertility? 1. Varicocele 2. Prostate cancer 3. Chronic prostatitis 4. Erectile dysfunction

1. Varicocele

What is the normal lab value for Urine Potassium?

25-100 mEq/L/day

What is the normal lab value for serum ALBUMIN?

3.5-5.5 g/dL

An emergency department nurse cares for a client who is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate (mL/hr) should the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.) ____ mL/hr

500 mL/hr Because IV pumps deliver in units of milliliters per hour, the pump would have to be set at 500 mL/hr to deliver 3 L (3000 mL) over 6 hours. 6x = 3000 x = 500

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

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

Which of the following characterize acute kidney injury (select all that apply): A. primary cause of death is infection B. almost always affects older people C. disease course is potentially reversible D. most common cause is diabetic neuropathy E. cardiovascular disease is the most common cause of death

A, C

You're caring for a patient with an indwelling catheter. The patient complains of spasm like pain at the catheter insertion site. Which of the following options below are other signs and symptoms the patient could experience or the nurse could observe if a urinary tract infection was present? SELECT-ALL-THAT-APPLY: A. Increased WBC B. Crystalluria C. Positive McBurney's Sign D. Feeling the need to void even though a catheter is present E. Dark and cloudy urine F. Cramping

A, D, E, & F

The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient (select all that apply)? A. Left ventricular function is documented. B. Controlling dysrhythmias will eliminate HF. C. Prescription for digoxin (Lanoxin) at discharge D. Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge E. Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen

A, D, E. The Joint Commission has identified these three core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.

One of the major advantages of peritoneal dialysis is that: A. no medications are required because of the enhanced efficiency of the peritoneal membranes in removing toxins B. the diet is less restricted and dialysis can be performed at home C. the dialysate is biocompatible and causes no long term consequences D. high glucose concentration of the dialysate causes a reduction in appetite promoting weight loss

B

A client with glomerulonephritis is at risk of developing acute renal failure. The nurse monitors the client for which sign of this complication? a) bradycardia b) hypertension c) decreased cardiac output d) decreased central venous pressure

B - Acute renal failure caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of acute renal failure is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute renal failure from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for renal failure.

A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? (SATA) a. Nocturia b. Flank pain c. Increased abdominal girth d. Dysuria e. Hematuria f. Diarrhea

B, C, E ~ Clients with PKD experience abdominal distention that manifests as flank pain and increased abdominal girth. Bloody urine is also present with tissue damage secondary to PKD. Clients with PKD often experience constipation, but would not report nocturia or dysuria.

Normal Renal Function Values

Blood Urea Nitrogen (BUN): 10 to 20 mg/dL ( BUN= seizures in ESRD!) Serum creatinine: 0.6 to 1.2 mg/dL Serum uric acid: 3 to 7 mg/dL Urine Specific gravity- 1.010- 1.030 Urine Creatinine clearance- 85- 135 Glomerular filtration rate- 125

A patient with a history of end-stage kidney disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for his scheduled hemodialysis. Which assessments should the nurse prioritize before, during, and after his treatment? A.Level of consciousness B. Blood pressure and fluid balance C.Temperature, heart rate, and blood pressure D.Assessment for signs and symptoms of infection

Blood pressure and fluid balance Although all of the assessments are relevant to the care of a patient receiving hemodialysis, the nature of the procedure indicates a particular need to monitor the patient's blood pressure and fluid balance.

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

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

A nurse is caring for a client following a cystoscopy. Which assessment finding requires physician notification? a) bladder spasm b) complaints of fullness and burning in the bladder c) clots in the urine d) back pain

C - Back pain, bladder spasms, and feelings of fullness and burning in the bladder may be experienced by the client following a cystoscopy. Warm tub baths, mild analgesics, and antispasmodics will provide relief. Pink-tinged urine is common but any bright red bleeding or clots in the urine should be reported to the physician.

A nurse reviews laboratory results for a client with glomerulonephritis. The client's glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (SATA) a. Excessive GFR b. Normal GFR c. Reduced GFR d. Potential for fluid overload e. Potential for dehydration

C, D ~ The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid.

Which invasive method monitors blood volume and venous return? Pulmonary artery pressure Arterial blood gas Central venous pressure (CVP) Intra-arterial pressure

Central venous pressure (CVP)

A patient who has just been admitted with pulmonary edema is scheduled to receive these medications. Which medication should the nurse question? a. furosemide (Lasix) 40 mg b. captopril (Capoten) 25 mg c. digoxin (Lanoxin) 0.125 mg d. carvedilol (Coreg) 3.125 mg

D Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other medications are appropriate for the patient with ADHF.

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

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

During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do for the patient? A.Administer hypertonic saline. B.Administer a blood transfusion C.Decrease the rate of fluid removal. D.administer antiemetic medications.

Decrease the rate of fluid removal. The patient is experiencing hypotension from a rapid removal of vascular volume. The rate and volume of fluid removal will be decreased, and 0.9% saline solution may be infused. Hypertonic saline is not used because of the high sodium load. A blood transfusion is not indicated. Antiemetic medications may help the nausea but would not help the hypovolemia.

Deficient Fluid Symptoms

Decreased urine output Reduction in body weight Decreased skin turgor Dry mucous membranes Hypotension Tachycardia Vomiting & diarrhea

Excess fluid symptoms

Dyspnea Jugular vein distension Peripheral edema Hypertension Pulmonary edema Congestive heart failure Cerebral edema

An​ OB/GYN nurse is counseling women with heart failure about pregnancy and risk factors. The nurse recommends that the women prevent pregnancy. Which is the most important risk factor that contributes to this​ recommendation? Ejection fraction​ (EF) of​ 38% Blood pressure of​ 126/80 mmHg Previous miscarriages Cholesterol level of 220​ mg/dL

Ejection fraction​ (EF) of​ 38% Rationale: A normal EF is 50-​75%. An EF of less than​ 40% is a maternal risk factor for major cardiac complications. A blood pressure of​ 126/80 mmHg is within normal range. Previous miscarriages and a high cholesterol level of 220​ mg/dL would not necessarily contraindicate pregnancy.

A 75-year-old patient presents with high blood pressure, dyspnea on exertion, and a low tolerance from usual activity. The patient has lost 15 pounds since their last physical and states, "I just don't ever seem to feel like eating anymore." Which diagnosis should the nurse suspect for this patient? Heart failure Anorexia nervosa Deep vein thrombosis (DVT) Hypertension

Heart failure

Which correctly describes the effect on the body of the Frank-Starling mechanism? ANSWER Increased cardiac output (CO) caused by an increased cardiac contractile force Increased vascular resistance due to decreased CO Inhibition of water excretion and salt and water retention in the kidneys Hypertrophy of myocardial muscle due to increased cardiac workload

Increased cardiac output (CO) caused by an increased cardiac contractile force

Which action is part of the physical assessment that the nurse would perform for a patient with heart failure? Observing shortness of breath Discussing history of hypertension Asking about recent weight gain Inspecting for presence and degree of edema

Inspecting for presence and degree of edema

What are the normal Creatinine Clearance values?

Men 107-139 mL/min Women 87-107 mL/min

African Americans are more at risk for heart failure. What are the most important risk factors in this​ population? (Select all that​ apply.) Obesity Renal insufficiency Hypotension Hypertension Low levels of HDL

Obesity Renal insufficiency Hypertension Low levels of HDL ​Rationale: Hypertension, renal​ insufficiency, obesity, and low levels of HDL​ (which increases risk of​ atherosclerosis) are all contributing risk factors for heart failure in the​ African-American population. Hypotension is not a risk factor for heart failure in any population.

A patient with heart failure has weakened ventricular contractions and decreased cardiac output. The nurse should anticipate an order for which medication to improve cardiac contractility? Positive inotropic Loop diuretic Nitrate Alpha blocker

Positive inotropic

An​ 86-year-old man visits the clinic and asks about risk factors for heart disease. Which modifiable risk factors would the nurse discuss with this​ client? (Select all that​ apply.) Ethnicity Smoking Exercise Sex Nutrition

Smoking Exercise Nutrition

List the GFR rates for the different stages of renal failure.

Stage 1 = <90 mL/min Stage 2 = <60 mL/min Stage 3 = <45 mL/min Stage 4 = <30 mL/min Stage 5 = <15 mL/min

A nurse working in a community health center is developing an educational program for clients who are at risk for heart failure. Which modifiable risk factor should be included in this​ program? (Select all that​ apply.) Stress Gender Obesity Cigarette smoking Age Race

Stress Obesity Cigarette smoking

The nurse is performing an assessment on a​ 57-year-old client with newly diagnosed heart failure. The product of which factors determine a​ client's cardiac​ output? Heart rate and ejection fraction Heart rate and urinary output Stroke volume and urinary output Stroke volume and heart rate

Stroke volume and heart rate

The nurse is performing an assessment on a​ 57-year-old client with newly diagnosed heart failure. The product of which factors determine a​ client's cardiac​ output? Heart rate and urinary output Stroke volume and heart rate Stroke volume and urinary output Heart rate and ejection fraction

Stroke volume and heart rate ​Rationale: The correct formula for cardiac output​ (CO) is: CO​ = heart rate​ (HR) x stroke volume​ (SV). To increase blood circulation​ (CO), there needs to be an increased heart​ rate, increased stroke​ volume, or both. Stroke volume is the amount of blood exerted from the left ventricle per beat and can be altered by factors of​ preload, contractility, and afterload.

A client with heart failure is being discharged home with his wife. What is the priority goal for this​ client? To walk 5 miles per day To not gain more than 5 pounds in a week To consume a​ high-salt diet To lose 2 pounds every week

To not gain more than 5 pounds in a week ​Rationale: Clients with heart failure should be on a​ no-salt diet due to fluid retention. Walking 5 miles per day is not a safe or appropriate goal for a client with heart failure. Losing 2 pounds per week is not an appropriate​ goal, as the client could become fluid deficient. Gaining 2-3 pounds in 24 hours or 5 or more pounds in a week is not an appropriate goal for a client with heart failure and must be​ re-evaluated by a healthcare provider.

A client is learning about a​ low-sodium diet due to heart failure. Which food does the client select for lunch to demonstrate understanding of a​ low-sodium diet? Hot dog Ham Turkey breast Shrimp

Turkey ​Rationale: The best selection for the client is 3.5 ounces of​ turkey, as it contains between 63 and 76 mg of sodium. A client who has heart failure should not consume more than​ 2,000 mg of sodium per day. A​ 3.5-ounce piece of roasted ham contains approximately​ 1,400 mg of sodium. A hot dog contains approximately 585 mg of sodium. Three ounces of shrimp contains 190 mg of sodium.

What is the normal Urine Glucose lab value?

ZERO

The patient with chronic kidney disease is considering whether to use peritoneal dialysis (PD) or hemodialysis (HD). What are advantages of PD when compared to HD (select all that apply)? a. Less protein loss b. Rapid fluid removal c. Less cardiovascular stress d. Decreased hyperlipidemia e. Requires fewer dietary restrictions

c, e. Peritoneal dialysis is less stressful for the cardiovascular system and requires fewer dietary restrictions. Peritoneal dialysis actually contributes to more protein loss and increased hyperlipidemia. The fluid and creatinine removal are slower with peritoneal dialysis than hemodialysis.

A 56-year-old woman with type 2 diabetes mellitus and chronic kidney disease has a serum potassium level of 6.8 mEq/L. The nurse should assess the patient for A.fatigue. B. flank tenderness. C.cardiac dysrhythmias. D.elevated triglycerides.

cardiac dysrhythmias. Hyperkalemia is the most serious electrolyte disorder associated with kidney disease. Fatal dysrhythmias can occur when the serum potassium level reaches 7 to 8 mEq/L. Fatigue and hypertriglyceridemia may be present but do not require urgent intervention. Tenderness or pain over the kidneys is not expected in CKD.

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. Intrarenal causes of acute kidney injury (AKI) include conditions that cause direct damage to the kidney tissue, including nephrotoxic drugs, acute glomerulonephritis, and tubular obstruction by myoglobin, or prolonged ischemia. Anaphylaxis and other prerenal problems are frequently the initial cause of AKI. Renal stones and bladder cancer are among the postrenal causes of AKI.

Which patient arriving at the urgent care center will the nurse assess first? a. Patient with acute right eye pain that occurred while using home power tools b. Patient with purulent left eye discharge, pruritus, and conjunctival inflammation c. Patient who is complaining of intense discomfort after an insect crawled into the right ear d. Patient who has Ménière's disease and is complaining of nausea, vomiting, and dizziness

ANS: A The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss.

It is most important that the nurse ask a patient admitted with acute glomerulonephritis about a. history of kidney stones. b. recent sore throat and fever. c. history of high blood pressure. d. frequency of bladder infections.

ANS: B Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by kidney stones, hypertension, or urinary tract infection (UTI). DIF: Cognitive Level: Apply (application) REF: 1074 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? a. Assess the patient with a Rinne test. b. Place a fall-risk bracelet on the patient. c. Ask the patient to watch the mouths of staff when they are speaking. d. Remind unlicensed assistive personnel to speak loudly to the patient.

ANS: B Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls. The Rinne test is used to check hearing. Reading lips and louder speech are compensatory behaviors for decreased hearing.

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patient's central venous pressure (CVP) is decreased. c. The patient has a level 7 (0 to 10 point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevated.

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

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV b. Mannitol (Osmitrol) 100 mg IV c. Betaxolol (Betoptic) 1 drop in each eye d. Acetazolamide (Diamox) 250 mg orally

ANS: B The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered.

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a. Administer the ordered analgesic. b. Check the patient's oxygen saturation. c. Examine the eye for evidence of trauma. d. Assess each of the cranial nerve functions.

ANS: B The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take.

Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene immediately? a. UAP raise the side rails on the bed. b. UAP turn on the patient's television. c. UAP turn the patient to the right side. d. UAP place an emesis basin at the bedside.

ANS: B Watching television may exacerbate the symptoms of an acute attack of Ménière's disease. The other actions are appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack

A client develops a renal disorder after taking an antibiotic that is known to have nephrotoxic effects. The nurse adds a standardized care plan to the client's medical record for which disorder? A) Polycystic kidney disease B) Glomerulonephritis C) Acute renal failure D) Chronic renal failure

ANS: C

A patient who has undergone a left tympanoplasty should be instructed to a. remain on bed rest. b. keep the head elevated. c. avoid blowing the nose. d. irrigate the left ear canal.

ANS: C Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.

Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. c. The patient cleans the catheter while taking a bath each day. d. The patient slows the inflow rate when experiencing abdominal pain.

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

The nurse observes unlicensed assistive personnel (UAP) taking the following actions when caring for a female patient with a urethral catheter. Which action requires that the nurse intervene? a. Taping the catheter to the skin on the patient's upper inner thigh b. Cleaning around the patient's urinary meatus with soap and water c. Disconnecting the catheter from the drainage tube to obtain a specimen d. Using an alcohol-based gel hand cleaner before performing catheter care

ANS: C The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection (UTI). The other actions are appropriate and do not require any intervention.

A client has been educated about activities that can increase intraocular pressure. Which statement indicates that the client requires further teaching? a. "I will avoid wearing tight shirt collars and ties." b. "I will take stool softeners daily to prevent straining." c. "I will try not to sneeze, cough, or blow my nose." d. "I will not put my arms above my head."

ANS: D Arm position does not influence intraocular pressure. All other activities listed decrease the incidence of increased intraocular pressure.

The nurse has admitted a client with uremia. The nurse questions the client about a history of which health problem? A) Polycystic kidney disease B) End-stage renal failure C) Pyelonephritis D) Cystitis

ANS:B

The nurse is providing care to a patient diagnosed with heart failure. Which intervention is not necessary when monitoring the patient's fluid volume? Weighing the patient daily Auscultating lung sounds every 4 hours Allowing for rest periods Monitoring intake and output

Allowing for rest periods

Which of the following symptoms would the nurse expect to find in the patient diagnosed with bladder cancer? A) Dysuria and urgency B) Painless hematuria C) Suprapubic pain with nausea and vomiting D) Pyuria and incontinence

Answer: B. Painless gross hematuria is the most common symptom of bladder cancer. Dysuria and urgency are common findings in UTI. Suprapubic pain with nausea and vomiting may be found with nephrolithiasis (kidney stones). Pyuria and incontinence are not associated with bladder cancer.

The nurse knows that all but which of the following are measures to promote urinary continence: A) Stopping smoking B) Pelvic floor exercises C) Avoiding constipation D) Taking showers not baths

Answer: D. Taking showers and not baths would be appropriate for the patient with recurrent UTI's. Smoking can increase cough which can in turn increase incontinence. Pelvic floor exercises help strengthen muscles and will help with incontinence. Constipation should be avoided as this can promote incontinence.

A client with nephrolithiasis arrives at a clinic for a follow-up visit. The laboratory analysis of the stone that the client passed 1 week ago indicates that the stone is composed of calcium oxalate. The nurse tells the client to avoid consuming which food item? a) lentils b) strawberries c) lettuce d) pasta

B - Foods that raise urinary oxalate excretion include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea. Of the options provided, the client will be instructed to avoid strawberries.

During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply): A. hypotension B. ECG changes C. hypernatremia D. pulmonary edema E. urine with high specific gravity

B, D

A client with chronic renal failure has a new medication order for epoetin alfa (Epogen). The nurse plans to give this medication in which of the following ways? a) with a full glass of water b) diluted in juice to enhance taste c) subcutaneously d) with an antacid

C - Epoetin alfa is erythropoietin that has been manufactured through the use of recombinant DNA technology. It is used to treat anemia in the client with chronic renal failure. The medication may be administered subcutaneously or intravenously.

16. A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's a. weight increases from 120 pounds to 122 pounds over 3 days. b. liver is palpable 2 cm below the ribs on the right side. c. serum potassium level is 3.0 mEq/L after 1 week of therapy. d. has 1 to 2+ edema in the feet and ankles in the morning.

C Rationale: Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity, which can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level. Cognitive Level: Application Text Reference: pp. 832-833 Nursing Process: Assessment NCLEX: Physiological Integrity

During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. jugular vein atherosclerosis. c. elevated right atrial pressure. d. incompetent jugular vein valves.

C The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to a. hold a card and fixate on the center dot. b. report any burning or pain at the IV site. c. remain still while the cornea is anesthetized. d. let the examiner know when images shown appear clear.

ANS: B Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines.

RIFLE defines three stages of AKI based on changes in: A. blood pressure and urine osmolality B. fractional excretion of urinary sodium C. estimation of GFR with the MDRD equation D. serum creatinine or urine output from baseline

D. serum creatinine or urine output from baseline

What is the normal Glomerular Filtration Rate (GFR)?

Men >130 mL/min/m2 Women >120 mL/min/m2

The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse take first? a. Apply ice packs to both eyes. b. Flush the eyes with sterile saline. c. Apply antiseptic ophthalmic ointment to the eyes. d. Cover the eyes with dry sterile patches and shields.

ANS: B Flushing of the eyes immediately is indicated for chemical exposure. Emergency treatment of a burn or foreign-body injury to the eyes includes protecting the eyes from further injury by covering them with dry sterile dressings and protective shields. Flushing of the eyes immediately is indicated only for chemical exposure. In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available

The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse take first? a. Apply ice packs to both eyes. b. Flush the eyes with sterile saline. c. Apply antiseptic ophthalmic ointment to the eyes. d. Cover the eyes with dry sterile patches and shields.

ANS: B Flushing of the eyes immediately is indicated for chemical exposure. Emergency treatment of a burn or foreign-body injury to the eyes includes protecting the eyes from further injury by covering them with dry sterile dressings and protective shields. Flushing of the eyes immediately is indicated only for chemical exposure. In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available

A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection? a. Apply cold compresses at the first sign of recurrence. b. Discard all open or used cosmetics applied near the eyes. c. Wash the scalp and eyebrows with an antiseborrheic shampoo. d. Be examined for recurrent sexually transmitted infections (STIs).

ANS: B Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for sexually transmitted infection (STI) testing

A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection? a. Apply cold compresses at the first sign of recurrence. b. Discard all open or used cosmetics applied near the eyes. c. Wash the scalp and eyebrows with an antiseborrheic shampoo. d. Be examined for recurrent sexually transmitted infections (STIs).

ANS: B Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for sexually transmitted infection (STI) testing.

When planning teaching for a 59-year-old male patient with benign nephrosclerosis the nurse should include instructions regarding a. preventing bleeding with anticoagulants. b. monitoring and recording blood pressure. c. obtaining and documenting daily weights. d. measuring daily intake and output volumes.

ANS: B Hypertension is the major symptom of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis. DIF: Cognitive Level: Apply (application) REF: 1082 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about a. a low sodium diet. b. ways to avoid falls. c. how to apply sunscreen. d. the chemotherapy side effects.

ANS: B Intermittent vertigo occurs with acoustic neuroma, so the nurse should include information about how to prevent falls. Diet is not a risk factor for acoustic neuroma and no dietary changes are needed. Sunscreen would be used to prevent skin cancers on the external ear. Acoustic neuromas are benign and do not require chemotherapy

When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about a. a low sodium diet. b. ways to avoid falls. c. how to apply sunscreen. d. the chemotherapy side effects.

ANS: B Intermittent vertigo occurs with acoustic neuroma, so the nurse should include information about how to prevent falls. Diet is not a risk factor for acoustic neuroma and no dietary changes are needed. Sunscreen would be used to prevent skin cancers on the external ear. Acoustic neuromas are benign and do not require chemotherapy

The nurse is describing the pathophysiology of heart failure to a colleague. Which statement by the nurse is accurate regarding the compensatory mechanism in the development of heart failure? "Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output." "Gradual compensatory changes are initially benign but lead to decreased cardiac and renal functioning." "Increased renal function that occurs with aging causes a change in other systems to improve functioning." "Kidneys that are poorly perfused as a result of increased CO produce renin, which eventually decreases blood pressure (BP) and sodium retention."

"Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output." Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output. This is a compensatory change that occurs in the development of heart failure. Decreased, not increased, renal function that occurs with aging causes a change in other systems to improve functioning. Gradual compensatory changes are initially benign but lead to increased, not decreased, cardiac and renal functioning. Kidneys are poorly perfused as a result of decreased, not increased, CO and produce renin, which eventually decreases BP and sodium retention.

The nurse preceptor asks a new graduate to describe the pathophysiology of heart failure. Which response by the new graduate demonstrates a need for further teaching of the compensatory mechanisms involved in the development of heart failure? "Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output." "Increased cardiac output stimulates the sympathetic nervous system to increase heart rate." "The ventricles in the heart remodel and develop hypertrophy because of the chronic increase in fluid volume." "Atrial natriuretic peptide is released by the cardiac cells to help delay cardiac decompensation."

"Increased cardiac output stimulates the sympathetic nervous system to increase heart rate." Decreased, not increased, cardiac output stimulates the sympathetic nervous system (SNS) to increase heart rate. Compensatory mechanisms play a large role in the development of heart failure. Initially, cardiac output is increased because the cardiac muscles are able to accommodate the additional workload. This situation cannot last. Over time, the cardiac muscle will weaken, and cardiac output will begin to decrease. Decreased cardiac output causes the aortic baroreceptors to stimulate the sympathetic nervous system. The heart develops structural changes to accommodate additional fluid volume. The heart chambers and heart muscles enlarge to accommodate the additional fluid. As the cardiac output decreases, perfusion to the kidneys decreases. The kidneys respond by releasing renin to increase the vascular volume and venous return. Atrial natriuretic peptide is released by the cardiac cells to help delay cardiac decompensation. Atrial natriuretic peptide is a hormone that helps balance the effects of other hormones.

A patient gives the nurse health information before a scheduled intravenous pyelogram (IVP). Which item has the most immediate implications for the patient's care? a. The patient has not had food or drink for 8 hours. b. The patient lists allergies to shellfish and penicillin. c. The patient complains of costovertebral angle (CVA) tenderness. d. The patient used a bisacodyl (Dulcolax) tablet the previous night.

ANS: B Iodine-based contrast dye is used during IVP and for many computed tomography (CT) scans. The nurse will need to notify the health care provider before the procedures so that the patient can receive medications such as antihistamines or corticosteroids before the procedures are started. The other information is also important to note and document but does not have immediate implications for the patient's care during the procedures. DIF: Cognitive Level: Apply (application) REF: 1058 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? A. "It is essential that you maintain aseptic technique to prevent peritonitis. B. "You will be allowed a more liberal protein diet once you complete CAPD." C."It is important for you to maintain a daily written record of blood pressure and weight." D."You will need to continue regular medical and nursing follow-up visits while performing CAPD."

"It is essential that you maintain aseptic technique to prevent peritonitis." Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of preventing this from occurring. Although the other teaching statements are accurate, they do not have the potential for morbidity and mortality as does peritonitis, thus making that statement of highest priority.

A client is admitted to a medical unit with a diagnosis of congestive heart failure. The​ client's wife requests no physical therapy for the client because it​ "makes him​ tired." What is the​ nurse's most appropriate​ response? ​"Don't worry—our physical therapists will be​ careful." ​"That will only make him worse in the long​ run." ​"Moderate exercise is important to maintain his overall​ health." ​"I'll make a note in the chart that he is refusing physical​ therapy."

"Moderate exercise is important to maintain his overall​ health." ​Rationale: Family members may worry if a client has activity intolerance. They may discourage any activity and try to do everything for the client. The nurse should provide information and support to families while encouraging as much activity for the client as tolerated. The family should be given encouraging information about optimizing heart function and​ perfusion, without being falsely reassured or have their concerns belittled. Assisting the client and family with activity tolerance optimizes perfusion and overall homeostasis.

A 56-year-old man with a history of coronary artery disease is admitted with reports of dyspnea and fatigue. Upon physical examination, the nurse auscultates crackles halfway up his lung fields. An echocardiogram reveals reduced cardiac output. Which response should the nurse provide to the patient when he asks why a heart problem makes it hard for him to breathe? "The right side of your heart is too weak to pump blood effectively, so the blood is backing up and congesting your lungs." "The left side of your heart is too weak to pump blood effectively, so the blood is backing up and congesting your lungs." "The left side of your heart is too weak to pump enough blood to your lungs." "The right ventricle of your heart is not pumping properly."

"The left side of your heart is too weak to pump blood effectively, so the blood is backing up and congesting your lungs."

A patient with severe heart failure is beginning a new medication treatment and will be taking furosemide, a loop diuretic. Which warning should the nurse give the patient before beginning the treatment? "This medication will increase your risk of having a low potassium level." "You will most likely experience decreased urinary output." "Call your doctor if you notice any vision changes." "Call your doctor if you develop a dry, persistent cough."

"This medication will increase your risk of having a low potassium level."

The nurse is caring for a 43-year-old mother of two sons. The patient and her partner want to conceive another child; however, the patient has had complicated pregnancies before and has recently been showing significant symptoms related to heart failure. Which is the most appropriate statement by the nurse in response to the patient and her partner regarding their plan to conceive a third child? "You may want to consider other options, such as adoption or surrogacy. Your symptoms indicate that you are in stage I heart failure right now, and, unfortunately, pregnancy is contraindicated in patients like you." "You had difficulties with your two previous pregnancies, which means you are going to experience worsening symptoms during the next pregnancy. I would not want to have another pregnancy if I were you." "We need to monitor your status carefully. If you are showing signs of being in stage III or stage IV heart failure, pregnancy is contraindicated and the medical team here will advise you against getting pregnant." "While being ill is certainly not the most desired state for you to become pregnant in, we have an obstetrician and nursing team here who work exclusively with high-risk patients like you so that we can support you in any stage of health and pregnancy."

"We need to monitor your status carefully. If you are showing signs of being in stage III or stage IV heart failure, pregnancy is contraindicated and the medical team here will advise you against getting pregnant."

After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Elevate the patient's arm above the level of the heart. b. Report the patient's symptoms to the health care provider. c. Remind the patient about the need to take a daily low-dose aspirin tablet. d. Educate the patient about the normal vascular response after AVG insertion.

-B The patient's complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Magnesium hydroxide c. Acetaminophen (Tylenol) d. Calcium phosphate (PhosLo)

ANS: B Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.

What is the normal lab value for Urine Specific Gravity?

1.01-1.03

The nurse is teaching a patient who was recently diagnosed with heart failure about the need for a low-sodium diet. Which amount is the sodium limit that would be appropriate for this patient? 3.5—4 g/day 0.5—1 g/day 2.5—3 g/day 1.5—2 g/day

1.5—2 g/day

A nurse planning a community health program on cancer awareness includes the need for testicular self-examination. What target age group would have the highest priority for this educational program? 1. 5 to 12 years 2. 15 to 35 years 3. 30 to 45 years 4. Older than 50 years

2. 15 to 35 years

The nurse is caring for a patient who is newly diagnosed with an enlarged prostate. Which test does the nurse expect the health care provider to order to differentiate benign prostate hypertrophy (BPH) from prostate cancer? 1. Uroflowmetry 2. Transrectal ultrasound 3. White blood cell (WBC) count 4. Prostate-specific antigen (PSA) test

2. Transrectal ultrasound

The nurse is teaching a client how to apply eye medication. Which is the correct technique for applying ointment into the eye? a. From the middle out b. From the inner canthus to the outer canthus c. From the outer canthus to the inner canthus d. Against the inner aspect of the eyelid

ANS: B Ointment should be applied by pulling down the lower lid and forming a pocket. Application should proceed from the inner canthus toward the outer canthus, with the client tilting the head backward and looking up at the ceiling.

To prevent recurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating a. milk and cheese. b. sardines and liver. c. legumes and dried fruit. d. spinach, chocolate, and tea.

ANS: B Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones. DIF: Cognitive Level: Apply (application) REF: 1078 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a. questioning the patient about blurred vision. b. noting any changes in the patient's visual field. c. asking the patient to rate the pain using a 0 to 10 scale. d. assessing the patient's depth perception when climbing stairs.

ANS: B POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG

12. To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a. questioning the patient about blurred vision. b. noting any changes in the patient's visual field. c. asking the patient to rate the pain using a 0 to 10 scale. d. assessing the patient's depth perception when climbing stairs.

ANS: B POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.

The nurse is educating a patient regarding erectile dysfunction. What risk factor should the nurse be sure to discuss with the patient? 1. Orchitis 2. Epididymitis 3. Cryptorchidism 4. Atherosclerosis

4. Atherosclerosis

The nurse is assessing a male patient and suspects paraphimosis. What physical finding causes the nurse to determine this? 1. Curved or crooked penis 2. Inflammation of the testis 3. Abnormal prolonged erection of the penis 4. Permanent retracted position of the foreskin behind the penis

4. Permanent retracted position of the foreskin behind the penis

The nurse is preparing a patient for a cystoscopy in order to remove prostate tissue. What procedure does the nurse anticipate the healthcare provider will use to treat this patient? 1. Laser prostatectomy 2. Intraprostatic urethral stents 3. Transurethral incision of prostate (TUIP) 4. Transurethral resection of prostate (TURP)

4. Transurethral resection of prostate (TURP)

What is the normal lab value for Urine Protein?

<100 mg/dL

Kidney transplant recipient complains of having fever, chills, and dysuria over the course of the past 2 days, What is the first action the nurse should take? A. assess temperature and initiate workup to rule out infection B. provied warm cover for the patient and give 1 g acetaminophen orally C. reassure the patient that this is common after transplantation D. notify the nephrologist that the patient has developed symptoms of acute rejection

A

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

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

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

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

An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talking.

ANS: B Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend the nurse

A nurse is analyzing the laboratory results of a client with chronic renal failure who is receiving epoetin alfa (Epogen). The nurse interprets that the medication is having the expected effect if the results indicate an increase in which of the following levels? a) red blood cells b) potassium c) creatinine d) phosphorus

A - Epoetin alfa is erythropoietin that has been manufactured through the use of recombinant DNA technology. It is used to treat anemia in the client with chronic renal failure. The other levels rise as a result of the pathology of renal failure and have nothing to do with the effects of this medication.

A nurse is caring for a client who has just returned to the nursing unit after an intravenous pyelogram (IVP). The nurse determines that which of the following is important in the postprocedure care of this client? a) encouraging increased intake of oral fluids b) ambulating the client in the hallway c) encouraging the client to try to avoid frequently d) maintaining the client on bedrest

A - Following an IVP, the client should take in increased fluids to aid in the clearance of the dye used for the procedure. It is unnecessary to void frequently after the procedure. The client is usually allowed activity as tolerated without any specific activity guidelines.

A client diagnosed with cancer of the bladder has a nursing diagnosis of fear related to the uncertain outcome of upcoming cystectomy and urinary diversion. The nurse determines that this diagnosis is appropriate if the client makes which statement? a) I'm so afraid I won't live through all this b) what if I have no help at home after going through this awful surgery c) I'll never feel like myself once I can't go to the bathroom normally d) I wish I'd never gone to the doctor at all

A - In order for fear to be an actual diagnosis, the client must be able to identify the object of fear. In this question, the client is expressing a fear of the outcome related to surgery. The statement in option B relates to a nursing diagnosis of impaired home maintenance. Option C relates to a nursing diagnosis of disturbed body image. Option D is vague and nonspecific, and further assessment is needed to associate this statement with a nursing diagnosis.

An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talking.

ANS: B Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend the nurse.

A nurse has provided instructions to a female client with cystitis about measures to prevent recurrence. The nurse determines that the client needs further instruction if the client verbalizes to: a) take bubble baths for more effective hygiene b) wear underwater made of cotton or with cotton panels c) drink a glass of water and void after intercourse d) avoid wearing pantyhose while wearing socks

A - Measures to prevent cystitis include increasing fluid intake to 3 L per day; consuming an acid-ash diet; wiping front to back after urination; using showers instead of tub baths; drinking water and voiding after intercourse; avoiding bubble baths, feminine hygiene sprays, or perfumed toilet tissue or sanitary pads; and wearing clothes that "breathe" (cotton pants, no tight jeans, no pantyhose under slacks). Other measures include teaching pregnant women to void every 2 hours, and teaching menopausal women to use estrogen vaginal creams to restore vaginal pH.

Following an acute myocardial infarction, a previously healthy 67-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. angiotensin-converting enzyme (ACE) inhibitors. b. digitalis preparations. c. -adrenergic agonists. d. calcium channel blockers.

A ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The -adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure.

Which action will the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a. Monitor blood pressure frequently. b. Encourage patient to ambulate in room. c. Titrate nesiritide rate slowly before discontinuing. d. Teach patient about safe home use of the medication.

A Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Since the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration and is used for ADHF but not in a home setting.

6. A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to a. administer IV morphine sulfate 2 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase dopamine (Intropin) infusion by 2 mcg/kg/min. d. increase nitroglycerin (Tridil) infusion by 5 mcg/min.

A Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output but will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea. Cognitive Level: Analysis Text Reference: pp. 828-829 Nursing Process: Implementation NCLEX: Physiological Integrity

21. A patient with ADHF who is receiving nesiritide (Natrecor) asks the nurse how the medication will work to help improve the symptoms of dyspnea and orthopnea. The nurse's reply will be based on the information that nesiritide will a. dilate arterial and venous blood vessels, decreasing ventricular preload and afterload. b. improve the ability of the ventricular myocardium to contract, strengthening contractility. c. enhance the speed of impulse conduction through the heart, increasing the heart rate. d. increase calcium sensitivity in vascular smooth muscle, boosting systemic vascular resistance.

A Rationale: Nesiritide, a recombinant form of BNP, causes both arterial and venous vasodilation, leading to reductions in preload and afterload. Inotropic medications, such as dopamine and dobutamine, may be used in ADHF to improve ventricular contractility. Nesiritide does not increase impulse conduction or calcium sensitivity in the heart. Cognitive Level: Application Text Reference: p. 829 Nursing Process: Implementation NCLEX: Physiological Integrity

19. An outpatient who has developed heart failure after having an acute myocardial infarction has a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that will be of most concern to the nurse is that the patient a. has BP of 88/42. b. has an apical pulse rate of 56. c. complains of feeling tired. d. has 2+ pedal edema.

A Rationale: The patient's BP indicates that the dose of carvedilol may need to be decreased because the mean arterial pressure is only 57. Bradycardia is a frequent adverse effect of -Adrenergic blockade, but the rate of 56 is not as great a concern as the hypotension. -adrenergic blockade will initially worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Assessment NCLEX: Analysis

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for an increased dosage of the eye drops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eye drops can be prescribed for you."

ANS: B Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use, are not relieved by avoiding systemic absorption, and are not symptoms of glaucoma

1. A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to a. auscultate the lung sounds. b. assess the orientation. c. check the capillary refill. d. palpate the abdomen.

A Rationale: When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority. Cognitive Level: Application Text Reference: pp. 824-825 Nursing Process: Assessment NCLEX: Physiological Integrity

10. On your nursing care plan for a patient with a urinary tract infection, which of the following would be appropriate nursing interventions? SELECT-ALL-THAT-APPLY: A. Encourage voiding every 2-3 hours while awake. B. Restrict fluid intake to 1-2 liters per day. C. Monitor intake and output daily. D. The patient verbalizes the importance of using vaginal sprays to decrease reoccurrence of urinary tract infections prior to discharge home.

A & C (but for the test only A)

The nurse is caring for a patient who presents with difficulty breathing and low blood pressure (BP). The patient is sweating excessively. The nurse suspects heart failure. Which patient is the nurse most likely caring for? A 25-year-old African American woman A 76-year-old man with type 2 diabetes A 55-year-old man with a history of hypertension A 10-year-old girl with a poor appetite

A 10-year-old girl with a poor appetite Symptoms of heart failure in children present differently than in adults. Children may have difficulty breathing, excessive sweating, low BP, and poor feeding and growth. The other patients are adults and will present with various other symptoms, depending on the type of heart failure.

A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? a. The client has lost 11 pounds in the past 10 days. b. The client's urine specific gravity is 1.048. c. No blood is observed in the client's urine. d. The client's blood pressure is 152/88 mm Hg.

A ~ Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload.

Which assessment finding for this patient is most important to report to the health care provider? A. Heart rate 46 and prolonged QRS duration B. Crackles at lung bases and peripheral edema C. Confusion and 1+ deep tendon reflexes D. Nausea and abdominal distention

A ~ The bradycardia and QRS prolongation are caused by the markedly elevated serum potassium level; rapid action is needed to prevent cardiac arrest. The other findings are also associated with acute kidney injury and poor renal function but are not life threatening

The nurse is conducting discharge teaching with a client following insertion of a new AV fistula in the L arm for hemodialysis. The nurse will be sure to include which topics in discussions with this client? Select all that apply. A) Avoid carrying items with the left arm B) Assess the fistula daily for redness or drainage C) BP should be taken in the right arm only D) Sleep on the left side E) It is expected to have some bleeding at the access site after a dialysis treatment

A, B, C

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse should take which actions? Select all that apply. A. Check the level of the drainage bag. B. Reposition the client to his or her side. C. Place the client in good body alignment. D. Check the peritoneal dialysis system for kinks. E. Contact the primary health provider F. Increase the flow of the peritoneal dialysis solution

A, B, C, D

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L. The nurse should plan which actions as a priority? Select all that apply. A. Place the client on a cardiac monitor B. Notify the HCP C. Put the client on NPO status except for ice chips D. Review the client's medications to determine if any contain or retain potassium E. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration

A, B, D

A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the nurse include in this client's discharge teaching? (SATA) a. Take your blood pressure every morning. b. Weigh yourself at the same time each day. c. Adjust your diet to prevent diarrhea. d. Contact your provider if you have visual disturbances. e. Assess your urine for renal stones.

A, B, D ~ A client who has PKD should measure and record his or her blood pressure and weight daily, limit salt intake, and adjust dietary selections to prevent constipation. The client should notify the provider if urine smells foul or has blood in it, as these are signs of a urinary tract infection or glomerular injury. The client should also notify the provider if visual disturbances are experienced, as this is a sign of a possible berry aneurysm, which is a complication of PKD. Diarrhea and renal stones are not manifestations or complications of PKD; therefore, teaching related to these concepts would be inappropriate.

A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (SATA) a. Proteinuria b. Hypoalbuminemia c. Dehydration d. Lipiduria e. Dysuria f. Costovertebral angle (CVA) tenderness

A, B, D ~ Nephrotic syndrome is caused by glomerular damage and is characterized by proteinuria (protein level higher than 3.5 g/24 hr), hypoalbuminemia, edema, and lipiduria. Fluid overload leading to edema and hypertension is common with nephrotic syndrome; dehydration does not occur. Dysuria is present with cystitis. CVA tenderness is present with inflammatory changes in the kidney.

A70-year-old woman with chronic heart failure and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed for her to continue at home. Which response by the nurse is accurate? A. "The medication prevents blood clots from forming in your heart." B. "The medication dissolves clots that develop in your coronary arteries." C. "The medication reduces clotting by decreasing serum potassium levels." D. "The medication increases your heart rate so that clots do not form in your heart."

A. "The medication prevents blood clots from forming in your heart." Chronic heart failure causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K-dependent clotting factors.

The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to ADHF? A. Take medications as prescribed. B. Use oxygen when feeling short of breath. C. Only ask the physician's office questions. D. Encourage most activity in the morning when rested.

A. Take medications as prescribed. The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can be asked questions or can contact the health care provider if there is evidence of worsening HF.

A patient in the oliguric phase after an acute kidney injury has had a 250 mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient's fluid restriction for the next 24 hours?

ANS: 950 mL The general rule for calculating fluid restrictions is to add all fluid losses for the previous 24 hours, plus 600 mL for insensible losses: (250 + 100 + 600 = 950 mL).

A client has an eye prosthesis and needs to have it inserted into the eye socket. Place the following steps of how to insert an eye prosthesis in the correct order. (Select in order of priority.) a. Wash your hands. b. Explain the procedure to the client. c. Remove the prosthesis from its container and rinse it with tepid water. d. Cover the work area with a cloth or towel. e. Don gloves. f. Place the prosthesis between the thumb and forefinger of your dominant hand with the notched end of the prosthesis closest to the client's nose. g. Insert the prosthesis with the top edge slipping under the upper lid. h. Lift the client's upper lid using your nondominant hand. i. Retract the lower lid slightly until the bottom edge of the prosthesis slips behind it. j. Release your hand slowly. k. Gently release the upper eyelid.

ANS: b, a, d, e, c, h, f, g, k, i, j The proper procedure for inserting an eye prosthesis is to explain the procedure, wash hands, prepare your work area with a cloth or towel, apply gloves, remove the prosthesis from its container and rinse it, use your nondominant hand to open the client's upper eyelid, hold the prosthesis properly, insert the prosthesis with the top edge slipping under the lid, release the lid, retract the lower lid until the prosthesis slides into place behind the lower lid, and take your hand away slowly.

Which nursing action is most appropriate when caring for a client with a nursing dx of excess fluid volume r/t renal insufficiency? A) Teaching clients about sodium content of foods B) Administering vitamin D supplements C) Assessing and documenting clients energy level D) Observing for signs of hypocalcemia

ANS: A

A 22-yr-old patient tells the nurse at the health clinic that he has recently had some problems with erectile dysfunction. Which question should the nurse ask to assess for possible etiologic factors in this age group? a. "Do you use recreational drugs or drink alcohol?" b. "Do you experience an unusual amount of stress?" c. "Do you have cardiovascular or peripheral vascular disease?" d. "Do you have a history of an erection that lasted for 6 hours or more?"

ANS: A A common etiologic factor for erectile dysfunction (ED) in younger men is use of recreational drugs or alcohol. Stress, priapism, and cardiovascular illness also contribute to ED, but they are not common etiologic factors in younger men. DIF: Cognitive Level: Apply (application) REF: 1287 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 42-year-old woman with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient's room. b. Encourage increased oral fluid intake. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 30 degrees.

ANS: A A darkened, quiet room will decrease the symptoms of the acute attack of Ménière's disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort

A 42-year-old woman with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient's room. b. Encourage increased oral fluid intake. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 30 degrees.

ANS: A A darkened, quiet room will decrease the symptoms of the acute attack of Ménière's disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort.

In the emergency department, the nurse is caring for a client diagnosed with a hyphema. Which statement by the client indicates a need for further teaching? a. "When I get home, I can lie flat in bed and turn from side to side." b. "For a few days, I cannot even read a book or watch television." c. "I will need to protect the eye with a patch and shield." d. "I need to stay on bedrest and will try not to make any sudden movement."

ANS: A A hyphema is a hemorrhage in the anterior chamber of the eye due to blunt force such as a motor vehicle accident. For management of this condition, the client must be on bedrest but must remain in a semi-Fowler's position to prevent accumulation of blood around the optical center of the cornea. The client cannot lie flat in bed and rotate from side to side. The client cannot read a book or watch television and must protect the eye if paralytic eyedrops were used. The client needs to be as still as possible to prevent further bleeding.

The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is a. risk for falls related to dizziness. b. impaired verbal communication related to tinnitus. c. self-care deficit (bathing and dressing) related to vertigo. d. imbalanced nutrition: less than body requirements related to nausea.

ANS: A All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to "drop attacks," the major focus of nursing care is to prevent injuries associated with dizziness

The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is a. risk for falls related to dizziness. b. impaired verbal communication related to tinnitus. c. self-care deficit (bathing and dressing) related to vertigo. d. imbalanced nutrition: less than body requirements related to nausea.

ANS: A All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to "drop attacks," the major focus of nursing care is to prevent injuries associated with dizziness.

Which nursing action is of highest priority for a 68-year-old patient with renal calculi who is being admitted to the hospital with gross hematuria and severe colicky left flank pain? a. Administer prescribed analgesics. b. Monitor temperature every 4 hours. c. Encourage increased oral fluid intake. d. Give antiemetics as needed for nausea.

ANS: A Although all of the nursing actions may be used for patients with renal lithiasis, the patient's presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.

A 70-yr-old patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) is being discharged from the hospital today. Which patient statement indicates a need for the nurse to provide additional instruction? a. "I should call the doctor if I have incontinence at home." b. "I will avoid driving until I get approval from my doctor." c. "I should schedule yearly appointments for prostate examinations." d. "I will increase fiber and fluids in my diet to prevent constipation."

ANS: A Because incontinence is common for several weeks after a TURP, the patient does not need to call the health care provider if this occurs. The other patient statements indicate that the patient has a good understanding of post-TURP instructions. DIF: Cognitive Level: Apply (application) REF: 1274 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

28. During the preoperative assessment of the patient scheduled for a right cataract extraction and intraocular lens implantation, it is most important for the nurse to assess a. the visual acuity of the patient's left eye. b. how long the patient has had the cataract. c. for a white pupil in the patient's right eye. d. for a history of reactions to general anesthetics.

ANS: A Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not affect the perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics.

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first? a. Check blood pressure and heart rate. b. Administer morphine sulfate 4 mg IV. c. Transport to radiology for an intravenous pyelogram. d. Insert a urethral catheter and obtain a urine specimen.

ANS: A Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions are also important once the patient's cardiovascular status has been determined and stabilized. DIF: Cognitive Level: Apply (application

A patient with urinary obstruction from benign prostatic hyperplasia (BPH) tells the nurse, "My symptoms are much worse this week." Which response by the nurse is appropriate? a. "Have you taken any over-the-counter (OTC) medications recently?" b. "I will talk to the doctor about a prostate specific antigen (PSA) test." c. "Have you talked to the doctor about surgery such as transurethral resection of the prostate (TURP)?" d. "The prostate gland changes in size from day to day, and this may be making your symptoms worse."

ANS: A Because the patient's increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed, but more assessment about possible reasons for the sudden symptom change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer. DIF: Cognitive Level: Apply (application) REF: 1273 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A female patient being admitted with pneumonia has a history of neurogenic bladder as a result of a spinal cord injury. Which action will the nurse plan to take first? a. Ask about the usual urinary pattern and any measures used for bladder control. b. Assist the patient to the toilet at scheduled times to help ensure bladder emptying. c. Check the patient for urinary incontinence every 2 hours to maintain skin integrity. d. Use intermittent catheterization on a regular schedule to avoid the risk of infection.

ANS: A Before planning any interventions, the nurse should complete the assessment and determine the patient's normal bladder pattern and the usual measures used by the patient at home. All the other responses may be appropriate, but until the assessment is complete, an individualized plan for the patient cannot be developed. DIF: Cognitive Level: Apply (application) REF: 1052 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse is assessing a client who wishes to be considered as a potential donor for corneal transplantation. Which medical diagnosis at the time of death excludes the client from consideration? a. Small cell lung cancer b. Chronic heart failure c. Profound nearsightedness d. History of detached retina

ANS: A Clients of any age may donate corneas as long as the corneas are clear and the client is free from infectious disease or cancer at the time of death. The other problems would not keep a client from donating corneas.

Which information will the nurse include for a patient contemplating a cochlear implant? a. Cochlear implants require training in order to receive the full benefit. b. Cochlear implants are not useful for patients with congenital deafness. c. Cochlear implants are most helpful as an early intervention for presbycusis. d. Cochlear implants improve hearing in patients with conductive hearing loss.

ANS: A Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness.

A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The purpose of maintaining the head in a prescribed position b. The use of eye patches to reduce movement of the operative eye c. The need to wear dark glasses to protect the eyes from bright light d. The procedure for dressing changes when the eye dressing is saturated

ANS: A Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. The dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure

A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The purpose of maintaining the head in a prescribed position b. The use of eye patches to reduce movement of the operative eye c. The need to wear dark glasses to protect the eyes from bright light d. The procedure for dressing changes when the eye dressing is saturated

ANS: A Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. The dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure

The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A Tono-pen will be applied to the surface of the eye. b. The test involves reading a Snellen chart from 20 feet. c. Medications will be used to dilate the pupils for the test. d. The examination involves checking the pupil's reaction to light.

ANS: A Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders.

A patient has elevated blood urea nitrogen (BUN) and serum creatinine levels. Which bowel preparation order would the nurse question for this patient who is scheduled for a renal arteriogram? a. Fleet enema b. Tap-water enema c. Senna/docusate (Senokot-S) d. Bisacodyl (Dulcolax) tablets

ANS: A High-phosphate enemas, such as Fleet enemas, should be avoided in patients with elevated BUN and creatinine because phosphate cannot be excreted by patients with renal failure. The other medications for bowel evacuation are more appropriate. DIF: Cognitive Level: Apply (application) REF: 1055 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse will inform a patient with cancer of the prostate that side effects of leuprolide (Lupron) may include a. flushing. c. infection. b. dizziness. d. incontinence.

ANS: A Hot flashes may occur with decreased testosterone production. Dizziness may occur with the a-blockers used for benign prostatic hyperplasia. Urinary incontinence may occur after prostate surgery, but it is not an expected side effect of medication. Risk for infection is increased in patients receiving chemotherapy. DIF: Cognitive Level: Understand (comprehension) REF: 1280 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A client comes to the emergency department with periorbital ecchymosis of the right eye. Which is the nurse's priority action? a. Apply an ice pack to the affected eye. b. Patch the eye to prevent eye movement. c. Assess the client's vision in both eyes. d. Irrigate the affected eye with normal saline.

ANS: A Ice will cause capillary vasoconstriction, thereby decreasing swelling and capillary oozing. Treatment with ice begins at the time of injury. Whenever the eye or surrounding tissue is injured, visual acuity is assessed next.

A 75-year-old patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Experiment with volume and hearing ability in a quiet environment initially. b. Keep the volume low on the hearing aids for the first week while adjusting to them. c. Add a second hearing aid after making the initial adjustment to the first hearing aid. d. Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.

ANS: A Initially the patient should use the hearing aids in a quiet environment like the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used

A 75-year-old patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Experiment with volume and hearing ability in a quiet environment initially. b. Keep the volume low on the hearing aids for the first week while adjusting to them. c. Add a second hearing aid after making the initial adjustment to the first hearing aid. d. Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.

ANS: A Initially the patient should use the hearing aids in a quiet environment like the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.

A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care? a. Teach the patient about the use of antifungal medications. b. Tell the patient to avoid tub baths until the symptoms resolve. c. Instruct the patient to refer recent sexual partners for treatment. d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Monilial urethritis is caused by a fungus and antifungal medications such as nystatin (Mycostatin) or fluconazole (Diflucan) are usually used as treatment. Because monilial urethritis is not sexually transmitted, there is no need to refer sexual partners. Warm baths and NSAIDS may be used to treat symptoms. DIF: Cognitive Level: Apply (application) REF: 1071 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse will plan to teach a 67-yr-old patient who has been diagnosed with orchitis about a. pain management. b. emergency surgery. c. application of heat to the scrotum. d. aspiration of fluid from the scrotal sac.

ANS: A Orchitis is very painful, and effective pain management will be needed. Heat, aspiration, and surgery are not used to treat orchitis. DIF: Cognitive Level: Apply (application) REF: 1284 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse is developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care? a. Discussing the need for sexually transmitted infection testing b. Applying topical corticosteroids to prevent further inflammation c. Assisting with applying for community visual rehabilitation services d. Educating about the use of antiviral eyedrops to treat the infection

ANS: A Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for sexually transmitted infection (STI) testing. AIC is treated with antibiotics. Antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate

The nurse is developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care? a. Discussing the need for sexually transmitted infection testing b. Applying topical corticosteroids to prevent further inflammation c. Assisting with applying for community visual rehabilitation services d. Educating about the use of antiviral eyedrops to treat the infection

ANS: A Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for sexually transmitted infection (STI) testing. AIC is treated with antibiotics. Antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate.

The nurse is assessing a 65-year-old patient for presbyopia. Which instruction will the nurse give the patient before the test? a. "Hold this card and read the print out loud." b. "Cover one eye at a time while reading the wall chart." c. "You'll feel a short burst of air directed at your eyeball." d. "A light will be used to look for a change in your pupils."

ANS: A The Jaeger card is used to assess near vision problems and presbyopia in persons over 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test.

What glomerular filtration rate (GFR) would the nurse estimate for a 30-year-old patient with a creatinine clearance result of 60 mL/min? a. 60 mL/min b. 90 mL/min c. 120 mL/min d. 180 mL/min

ANS: A The creatinine clearance approximates the GFR. The other responses are not accurate. DIF: Cognitive Level: Understand (comprehension) REF: 1056 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient complains of "popping" in the ear. c. The patient frequently asks the nurse to repeat information. d. The patient states that the right ear has a feeling of fullness.

ANS: A The fever indicates that the infection may not be resolved and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, and decreased hearing are symptoms of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment.

Which patient arriving at the urgent care center will the nurse assess first? a. Patient with acute right eye pain that occurred while using home power tools b. Patient with purulent left eye discharge, pruritus, and conjunctival inflammation c. Patient who is complaining of intense discomfort after an insect crawled into the right ear d. Patient who has Ménière's disease and is complaining of nausea, vomiting, and dizziness

ANS: A The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for an increased dosage of the eye drops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eye drops can be prescribed for you."

ANS: B Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use, are not relieved by avoiding systemic absorption, and are not symptoms of glaucoma.

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)? a. Pyridium may cause photosensitivity b. Pyridium may change the urine color. c. Take the Pyridium for at least 7 days. d. Take Pyridium before sexual intercourse.

ANS: B Patients should be taught that Pyridium will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Pyridium does not cause photosensitivity. Taking Pyridium before intercourse will not be helpful in reducing the risk for UTI. DIF: Cognitive Level: Apply (application) REF: 1067 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 32-year-old man who is being admitted for a unilateral orchiectomy for testicular cancer does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is best for the nurse to take? a. Ask the patient if he has any questions or concerns about the diagnosis and treatment. b. Document the patient's lack of communication on the chart and continue preoperative care. c. Assure the patient's wife that concerns about sexual function are common with this diagnosis. d. Teach the patient and the wife that impotence is rarely a problem after unilateral orchiectomy.

ANS: A The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, the nurse should not offer education about complications after orchiectomy. Documentation of the patient's lack of interaction is not an adequate nursing action in this situation.

Which medication taken at home by a 47-year-old patient with decreased renal function will be of most concern to the nurse? a. ibuprofen (Motrin) b. warfarin (Coumadin) c. folic acid (vitamin B9) d. penicillin (Bicillin LA)

ANS: A The nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and should be avoided in patients with impaired renal function. The nurse also should ask about reasons the patient is taking the other medications, but the medication of most concern is the ibuprofen. DIF: Cognitive Level: Apply (application) REF: 1052 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

After change-of-shift report, which patient should the nurse assess first? a. Patient with a urethral stricture who has not voided for 12 hours b. Patient who has cloudy urine after orthotopic bladder reconstruction c. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg d. Patient who voided bright red urine immediately after returning from lithotripsy

ANS: A The patient information suggests acute urinary retention, a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will also be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or possible intervention.

When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of a. persistent skin tenting b. rapid, deep respirations. c. bounding peripheral pulses. d. hot, flushed face and neck.

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

Several patients call the urology clinic requesting appointments with the health care provider as soon as possible. Which patient will the nurse schedule to be seen first? a. A 22-yr-old patient who has noticed a firm, nontender lump on his scrotum b. A 35-yr-old patient who is concerned that his scrotum "feels like a bag of worms" c. A 40-yr-old patient who has pelvic pain while being treated for chronic prostatitis d. A 70-yr-old patient who is reporting frequent urinary dribbling after a prostatectomy

ANS: A The patient's age and symptoms suggest possible testicular cancer. Some forms of testicular cancer can be very aggressive, so the patient should be evaluated by the health care provider as soon as possible. Varicoceles do require treatment but not emergently. Ongoing pelvic pain is common with chronic prostatitis. Urinary dribbling is a common problem after prostatectomy. DIF: Cognitive Level: Analyze (analysis) REF: 1285 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

The nurse will plan to teach the patient who is incontinent of urine following a radical retropubic prostatectomy to a. restrict oral fluid intake. b. do pelvic muscle exercises. c. perform intermittent self-catheterization. d. use belladonna and opium suppositories.

ANS: B Pelvic floor muscle training (Kegel) exercises are recommended to strengthen the pelvic floor muscles and improve urinary control. Belladonna and opium suppositories are used to reduce bladder spasms after surgery. Intermittent self-catheterization may be taught before surgery if the patient has urinary retention, but it will not be useful in reducing incontinence after surgery. The patient should have a daily oral intake of 2 to 3 L. DIF: Cognitive Level: Apply (application) REF: 1278 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse performing a focused examination to determine possible causes of infertility will assess for a. hydrocele. c. epididymitis. b. varicocele. d. paraphimosis.

ANS: B Persistent varicoceles are commonly associated with infertility. Hydrocele, epididymitis, and paraphimosis are not risk factors for infertility. DIF: Cognitive Level: Understand (comprehension) REF: 1285 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is performing an eye examination on a 76-year-old patient. The nurse should refer the patient for a more extensive assessment based on which finding? a. The patient's sclerae are light yellow. b. The patient reports persistent photophobia. c. The pupil recovers slowly after responding to a bright light. d. There is a whitish gray ring encircling the periphery of the iris.

ANS: B Photophobia is not a normally occurring change with aging, and would require further assessment. The other assessment data are common gerontologic differences and would not be unusual in a 76-year-old patient.

The nurse caring for a patient after cystoscopy plans that the patient a. learns to request narcotics for pain. b. understands to expect blood-tinged urine. c. restricts activity to bed rest for a 4 to 6 hours. d. remains NPO for 8 hours to prevent vomiting.

ANS: B Pink-tinged urine and urinary frequency are expected after cystoscopy. Burning on urination is common, but pain that requires opioids for relief is not expected. A good fluid intake is encouraged after this procedure. Bed rest is not required following cystoscopy. DIF: Cognitive Level: Apply (application) REF: 1060 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The following male patients recently arrived in the emergency department. Which one should the nurse assess first? a. A 19-yr-old patient who is complaining of severe scrotal pain b. A 60-yr-old patient with a nontender ulceration of the glans penis c. A 64-yr-old patient who has dysuria after brachytherapy for prostate cancer d. A 22-yr-old patient who has purulent urethral drainage and severe back pain

ANS: A The patient's age and symptoms suggest possible testicular torsion, which will require rapid treatment to prevent testicular necrosis. The other patients also require assessment by the nurse, but their history and symptoms indicate nonemergent problems (acute prostatitis, cancer of the penis, and radiation-associated urinary tract irritation). DIF: Cognitive Level: Analyze (analysis) REF: 1285 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

A 76-year-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first? a. Insert a urinary retention catheter. b. Schedule an intravenous pyelogram (IVP). c. Draw blood for a serum creatinine level. d. Administer lorazepam (Ativan) 0.5 mg PO.

ANS: A The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test but does not need to be done urgently.

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

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

A client with BPH asks why his enlarged prostate is causing difficulty with urination. Which is the nurse's most accurate response? a. "It compresses the urethra, blocking the flow of urine." b. "It presses on the kidneys, decreasing urine formation." c. "It secretes acids that weaken the bladder, causing dribbling." d. "It destroys nerves, decreasing awareness of a full bladder."

ANS: A The prostate gland encircles the urethra and bladder neck like a doughnut. Enlargement of the gland constricts the urethra and obstructs the outflow of urine by encroaching on the bladder opening. The other responses are inaccurate.

Which information will the nurse provide to the patient scheduled for refractometry? a. "You will need to wear sunglasses for a few hours after the exam." b. "The surface of your eye will be numb while the doctor does the exam." c. "You should not take any of your eye medicines before the examination." d. "The doctor will shine a bright light into your eye during the examination."

ANS: A The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? a. The patient has questions about the ordered eye drops. b. The patient has eye pain rated at a 5 (on a 0 to 10 scale). c. The patient has poor depth perception when wearing an eye patch. d. The patient complains that the vision has not improved very much.

ANS: B Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching but does not indicate that complications of the surgery may be occurring

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? a. The patient has questions about the ordered eye drops. b. The patient has eye pain rated at a 5 (on a 0 to 10 scale). c. The patient has poor depth perception when wearing an eye patch. d. The patient complains that the vision has not improved very much.

ANS: B Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching but does not indicate that complications of the surgery may be occurring.

The nurse is providing discharge teaching for a client with posterior uveitis. Which is the most important precaution for the nurse to teach the client? a. Correct technique for eyedrop instillation b. Clinical manifestations of retinal hemorrhage c. Correct technique for insertion of contact lenses d. Proper timing of opioid analgesics

ANS: A Treatment of posterior uveitis is symptomatic, with eyedrops used to dilate the pupil and decrease the inflammatory response. The client may have to instill eyedrops as frequently as every hour. This condition consists of inflammation of the retina—not a hemorrhage. Opioids are not prescribed to lessen the pain, but cool or warm compresses may be used for ocular pain.

5. Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding? a. OS 20/50; OD 20/40 b. OU 20/40; OS 50/20 c. OD 20/40; OS 20/50 d. OU 40/20; OD 50/20

ANS: A When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient's visual acuity

The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse's instructions for this test include asking the patient to a. stand 20 feet from the wall chart. b. follow the examiner's finger with the eyes only. c. look at an object far away and then near to the eyes. d. look straight ahead while a light is shone into the eyes.

ANS: A When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiner's fingers with the eyes tests extraocular movements.

A client receiving peritoneal dialysis has outflow that is 200 ml less than the inflow for 2 consecutive exchanges. Which actions would be appropriate for the nurse to take at this time? Select all that apply. A) Examine the abd dressing B) Change clients position C) Lower the drainage bag D) Continue to monitor the outflow in future exchanges E) Irrigate the peritoneal dialysis catheter

ANS: A, B, C

The nurse is conducting discharge teaching with a client following insertion of a new AV fistula in the L arm for hemodialysis. The nurse will be sure to include which topics in discussions with this client? Select all that apply. A) Avoid carrying items with the left arm B) Assess the fistula daily for redness or drainage C) BP should be taken in the right arm only D) Sleep on the left side E) It is expected to have some bleeding at the access site after a dialysis treatment

ANS: A, B, C

The nurse is reviewing the past medical history of a client diagnosed with chronic renal failure. Which conditions in the client's history most likely contributed to the client's renal failure? Select all that apply. A) DM type 1 B) HTN C) SLE D) Hypothyroidism E) Hiatal hernia

ANS: A, B, C

Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply)? a. Avoid commercial salt substitutes. b. Drink 1500 to 2000 mL of fluids daily. c. Take phosphate-binders with each meal. d. Choose high-protein foods for most meals. e. Have several servings of dairy products daily.

ANS: A, C, D Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is limited in patients requiring dialysis. Dairy products are high in phosphate and usually are limited.

The nurse in a health clinic receives requests for appointments from several patients. Which patient should be seen by the health care provider first? a. A 48-yr-old patient who has perineal pain and a temperature of 100.4° F b. A 58-yr-old patient who has a painful erection that has lasted more than 6 hours c. A 38-yr-old patient who reports that he had difficulty maintaining an erection twice last week d. A 68-yr-old patient who has pink urine after a transurethral resection of the prostate (TURP) 3 days ago

ANS: B Priapism can cause complications such as necrosis or hydronephrosis, and this patient should be treated immediately. The other patients do not require immediate action to prevent serious complications. DIF: Cognitive Level: Analyze (analysis) REF: 1283 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is teaching a postoperative client who had a keratoplasty. Which responses by the client require further teaching about safety in the home? (Select all that apply.) a. "We use throw rugs in the bathroom." b. "Our neighbors will be bringing food for a week." c. "We may have two extension cords in the living room." d. "Most of the furniture is placed against the wall, except for one rocking chair." e. "Every room has at least one window." f. "The hallway has low lighting."

ANS: A, C, D, F Throw rugs pose a danger of slipping or tripping. The client cannot see if the rug is flat or elevated. Extension cords should be placed under or behind the furniture to decrease the possibility of tripping. Furniture should be out of the normal walking pathway. Low lighting in the hallway may pose a problem when the client has a patch and shield over the operated eye. Lighting from a window should not be a problem. When neighbors bring food, the chance of burns occurring while cooking with limited vision is reduced.

The nurse assesses several clients. Which one is most likely to have secondary open-angle glaucoma? a. Client with gradual onset of blurred vision b. Client who has recently had eye surgery c. Client who sees halos around lights d. Client with reactive pupils and clear sclera

ANS: B Secondary open-angle glaucoma results from another condition that interferes with drainage of the aqueous humor such as recent eye surgery. Cataracts usually start with a slow onset of blurred vision but do not lead to secondary open-angle glaucoma. A late manifestation of primary open-angle glaucoma is seeing halos around lights; this is not considered secondary open-angle glaucoma. The client with reactive pupils and clear sclera has normal assessment findings, not related to secondary open-angle glaucoma.

The nurse is reviewing health care provider prescriptions for a client diagnosed with end-stage renal failure. Which diet should the nurse expect the provider to prescribe for this client? A) Increased protein, decreased CHO B) Restricted protein, increased CHO C) Increased potassium and sodium D) Increased phosphorus and magnesium

ANS: B

The nurse is teaching the client to perform peritoneal dialysis. The nurse reviews which essential action that will help to prevent the major complication of peritoneal dialysis? A) Monitor postvoid residuals B) Maintain strict aseptic technique during connection and disconnection C) Add heparin to dialysate at least once per day D) Change catheter site dressing twice daily

ANS: B

Following discharge teaching for a patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH), the nurse determines that additional instruction is needed when the patient says, a. "I will avoid driving until I get approval from my doctor." b. "I should call the doctor if I have any incontinence at home." c. "I will increase fiber and fluids in my diet to prevent constipation." d. "I should continue to schedule yearly appointments for prostate exams."

ANS: B Since incontinence is common for several weeks after a TURP, the patient does not need to call the health care provider if this occurs. The other patient statements indicate that the patient has a good understanding of post-TURP instructions.

The health care provider prescribes finasteride (Proscar) for a patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that a. he should change position from lying to standing slowly to avoid dizziness. b. his interest in sexual activity may decrease while he is taking the medication. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

ANS: B A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Although orthostatic hypotension may occur if the patient is also taking a medication for erectile dysfunction, it should not occur with finasteride alone. Improvement in symptoms of obstruction takes about 6 months. The medication does not cause hypertension. DIF: Cognitive Level: Apply (application) REF: 1271 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A client's prostate-specific antigen (PSA) level is 2.0 ng/mL. Which action by the nurse is most appropriate? a. Inform the client that the results are normal and no cancer has been detected. b. Inform the client that results are normal and schedule a digital rectal examination. c. Let the client know that the results are elevated and he is at risk for prostate cancer. d. Tell the client that cancer is indicated and that the health care provider recommends watchful waiting.

ANS: B A normal PSA in men younger than age 50 is less than 2.5 ng/mL. Although the finding is within normal limits for a PSA value, a client could have prostate cancer and not present with an elevated PSA. Also, laboratory findings should not be used as the sole screening tool. Without a digital rectal examination (DRE), the health care provider cannot know whether the client is in the early stages of prostate cancer. The client should be informed that although the level is within the normal range, he still needs a DRE.

Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? a. The patient complains of "fullness" in the ear. b. The patient's oral temperature is 100.8° F (38.1° C). c. The patient says "My hearing is worse now than it was right after surgery." d. There is a small amount of dried bloody drainage on the patient's dressing.

ANS: B An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of the accumulation of blood and drainage in the ear) are common after this surgery

Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? a. The patient complains of "fullness" in the ear. b. The patient's oral temperature is 100.8° F (38.1° C). c. The patient says "My hearing is worse now than it was right after surgery." d. There is a small amount of dried bloody drainage on the patient's dressing.

ANS: B An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of the accumulation of blood and drainage in the ear) are common after this surgery.

Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient's a. glucose. b. potassium. c. creatinine. d. phosphate.

ANS: B Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values would also be monitored in patients with CKD but would not affect whether the captopril was given or not.

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of corticosteroid eye drops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 1 to 2 days after the surgery

ANS: B Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery and opioids will not be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of corticosteroid eye drops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 1 to 2 days after the surgery

ANS: B Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery and opioids will not be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery.

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer b. Application of a warm compress to a patient's hordeolum c. Instruction about hand washing for a patient with herpes keratitis d. Looking for eye irritation in a patient with possible conjunctivitis

ANS: B Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer b. Application of a warm compress to a patient's hordeolum c. Instruction about hand washing for a patient with herpes keratitis d. Looking for eye irritation in a patient with possible conjunctivitis

ANS: B Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN.

A client is recovering from cataract surgery and needs medication to prevent a potential eye infection. Which drug does the nurse question administering to the client? a. Tobramycin (Tobrex) b. Apraclonidine (Iopidine) c. Gentamicin (Genoptic) d. Ciprofloxacin (Ciloxan)

ANS: B Apraclonidine is an adrenergic agonist that binds to eye receptors to reduce the amount of aqueous humor in the eye, resulting in decreased intraocular pressure. This medication usually is administered to clients with glaucoma. Tobramycin, gentamicin, and ciprofloxacin are anti-infectives.

Which statement indicates that the client understands teaching about the use of aspirin post-cataract surgery? a. "It may increase intraocular pressure after cataract surgery." b. "It changes the ability of the blood to clot and increases the risk of bleeding." c. "It reduces inflammation and might mask any symptoms of infection." d. "It can cause nausea and vomiting and may increase intraocular pressure."

ANS: B Aspirin disrupts platelet aggregation and increases the risk for bleeding after surgery. Aspirin may decrease inflammation but would not mask symptoms of infection. Aspirin does not cause increased intraocular pressure, nor does it typically cause nausea and vomiting. Aspirin should not mask signs of infection.

The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

ANS: B Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery

35. The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

ANS: B Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.

A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate).

ANS: B Because hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure.

A 58-yr-old patient with erectile dysfunction (ED) tells the nurse he is interested in using sildenafil (Viagra). Which action should the nurse take first? a. Assure the patient that ED is common with aging. b. Ask the patient about any prescription drugs he is taking. c. Tell the patient that Viagra does not always work for ED. d. Discuss the common adverse effects of erectogenic drugs.

ANS: B Because some medications can cause ED and patients using nitrates should not take sildenafil, the nurse should first assess for prescription drug use. The nurse may want to teach the patient about realistic expectations and adverse effects of sildenafil therapy, but this should not be the first action. Although ED does increase with aging, it may be secondary to medication use or cardiovascular disease. DIF: Cognitive Level: Analysis (analyze) REF: 1288 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with benign prostatic hyperplasia (BPH) with mild obstruction tells the nurse, "My symptoms have gotten a lot worse this week." Which response by the nurse is most appropriate? a. "I will talk to the doctor about ordering a prostate specific antigen (PSA) test." b. "Have you been taking any over-the-counter (OTC) medications recently?" c. "Have you talked to the doctor about surgical procedures such as transurethral resection of the prostate (TURP)?" d. "The prostate gland changes slightly in size from day to day, and this may be making your symptoms worse."

ANS: B Because the patient's increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed, but more assessment about possible reasons for the sudden symptom change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer.

A 58-year-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma due to a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon? a. Blood pressure is 102/58. b. Urine output is 20 mL/hr for 2 hours. c. Incisional pain level is reported as 9/10. d. Crackles are heard at bilateral lung bases.

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

How will the nurse assess for flank tenderness in a 30-year-old female patient with suspected pyelonephritis? a. Palpate along both sides of the lumbar vertebral column. b. Strike a flat hand covering the costovertebral angle (CVA). c. Push fingers upward into the two lowest intercostal spaces. d. Percuss between the iliac crest and ribs along the midaxillary line.

ANS: B Checking for flank pain is best performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain. DIF: Cognitive Level: Understand (comprehension) REF: 1055 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patient's abdomen appears bloated after the inflow.

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

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. "I will wash my hands often during the day." b. "I will remove my contact lenses at bedtime." c. "I will not share towels with my friends or family." d. "I will monitor my family for eye redness or drainage."

ANS: B Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact.

A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician? a. Teach the patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for causes of an increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis.

ANS: B Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.

The nurse is teaching a patient about an angiotensin-converting enzyme (ACE) inhibitor that was newly prescribed for heart failure. Which statement by the nurse describes the effect of this medication? "This drug will help increase your heart rate in order to have it pump more blood throughout your body." "This drug will cause your heart muscle to have stronger contractions, which will increase the amount of blood your heart can pump." "This drug is very effective at narrowing your blood vessels in order to push more blood to your heart." "This drug will help relax and open your blood vessels, which will lower your blood pressure and make it easier for your heart to pump."

"This drug will help relax and open your blood vessels, which will lower your blood pressure and make it easier for your heart to pump."

Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? a. The patient has type 1 diabetes. b. The patient has metastatic lung cancer. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with the human immunodeficiency virus.

ANS: B Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

A patient with an acute inflammation of the testes is diagnosed with orchitis. When taking medical history, about which conditions should the nurse inquire to find the possible cause of orchitis? Select all that apply. 1. Mumps 2. Asthma 3. Syphilis 4. Sinusitis 5. Tuberculosis

1. Mumps 3. Syphilis 5. Tuberculosis

The nurse is conducting a health history interview for a patient diagnosed with benign prostatic hyperplasia (BPH). Which questions are appropriate while assessing the patient's cognitive-perceptual pattern? Select all that apply. 1. "Do you experience nocturia?" 2. "Do you have bladder discomfort?" 3. "Do you experience urinary retention?" 4. "Do you have a sensation of incomplete voiding?" 5. "Do you experience anxiety about sexual dysfunction?"

2. "Do you have bladder discomfort?" 4. "Do you have a sensation of incomplete voiding?"

What is the normal lab value for serum PHOSPHORUS?

2.4-4.1 mg-dL

The nurse is reviewing the medication administration record for a patient with benign prostatic hypertrophy. Which medication inhibits of the synthesis of dihydrotestosterone? 1. Tadalafil 2. Silodosin 3. Finasteride 4. Saw palmetto

3. Finasteride

A patient reports an inability to attain erection, and the health care provider suspects a change in axial rigidity. For which diagnostic test will the nurse prepare the patient that is beneficial for diagnosis? 1. Digital rectal examination 2. Magnetic resonance imaging 3. Nocturnal penile tumescence 4. Duplex Doppler ultrasound study

3. Nocturnal penile tumescence

A patient who has cardiovascular disease has now developed erectile dysfunction. He is frustrated, because he cannot take erectogenic medications due to nitrate administration. What is a priority action by the nurse? 1. Give the patient choices for penile implant surgery 2. Recommend counseling for the patient and his partner 3. Obtain a thorough sexual, health, and psychosocial history 4. Assess levels of testosterone, prolactin, luteinizing hormone (LH), and thyroid hormones

3. Obtain a thorough sexual, health, and psychosocial history

The nurse is providing care to a patient who reports a tightened penile foreskin. When assessing this patient, the nurse is unable to pull the foreskin forward from the retracted position. Based on these data, which diagnosis does the nurse anticipate? 1. Priapism 2. Phimosis 3. Paraphimosis 4. Peyronie's disease

3. Paraphimosis

A male patient has human immunodeficiency virus (HIV) infection. When educating the patient regarding risk factors for the development of opportunistic diseases, what should the nurse include in the education? 1. Varicocele 2. Prostate cancer 3. Testicular cancer 4. Benign prostatic hyperplasia (BPH)

3. Testicular cancer

The nurse observes that a male child has the urethral meatus on the ventral surface of the penis. What condition does the nurse document this child has? 1. The child has orchitis. 2. The child has epididymitis. 3. The child has hypospadias. 4. The child has cryptorchidism.

3. The child has hypospadias.

What is the normal Osmolality of Urine?

300-900 mOsm/kg

What is the normal lab value for Urine RBCs?

<4 RBC/HPF

A patient is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by: A. progressive irreversible destruction of the kidneys B. a rapid decrease in urinary output and an elevated BUN C. an increasing creatinine clearance with a decrease in urinary output D. prostration, somnolence and confusion with coma and imminent death

A

An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, the nurse informs the patient that: A. successful transplantation usually provides a better quality of life than that offered by dialysis B. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available C. the immunosuppressive therapy that is required following transplantation causes fatal malignancies in many patients D. hemodialysis replaces the normal functioning of the kidneys and patients do not have to live with the continual fear of rejection

A

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most rapid action by the nurse? a. Oxygen saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Apical pulse rate of 106 beats/minute d. Urine output of 50 mL over 2 hours

A A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action.

A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about captopril, which statement by the patient indicates that teaching has been effective? a. "I will call for help when I need to get up to use the bathroom." b. "I will be sure to take the medication after eating something." c. "I will need to include more high-potassium foods in my diet." d. "I will expect to feel more short of breath for the next few days."

A Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE inhibitors are potassium sparing, and the nurse should not teach the patient to increase sources of dietary potassium. Increased shortness of breath is expected with initiation of -blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

Which patient should be taught preventive measures for CKD by the nurse because this patient is most likely to develop CKD? A.A 50-year-old white female with hypertension B.A 61-year-old Native American male with diabetes C.A 40-year-old Hispanic female with cardiovascular disease D.A 28-year-old African American female with a urinary tract infection

A 61-year-old Native American male with diabetes It is especially important for the nurse to teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because diabetes causes about 50% of CKD. This patient is the oldest, and Native Americans with diabetes develop CKD 6 times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. African Americans have the highest rate of CKD because hypertension is significantly increased in African Americans. A UTI will not cause CKD unless it is not treated or UTIs occur recurrently.

Patients with chronic kidney disease experience an increased incidence of cardiovascular disease related to (select all that apply): A. hypertension B. vascular calcifications C. a genetic predisposition D. hyperinsulinemia causing dyslipiemia E. increased high-density lipoprotein levels

A, B, D, E

The patient is treated for hyperkalemia and CCRT is initiated. Which actions will you delegate to the unlicensed assistive personnel (UAP) who are working with you to care for this patient? (SATA) A. Replace the ECG electrodes. B. Check the dialysis tubing for clot formation. C. Monitor for changes in orientation. D. Inspect the oral mucosa for dryness or cracking. E. Obtain a blood pressure and urine output hourly

A, E ~ Since placing ECG electrodes, obtaining vital signs, and measuring urine output are skills that are frequently done in daily care and require little modification between patients, these actions are appropriate to delegate to the UAP. Monitoring dialysis equipment and obtaining physical assessment data require nursing judgment and critical thinking and should be done by the RN

A 22-year-old female patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? a. Urinary urgency b. Left-sided flank pain c. Intermittent hematuria d. Burning with urination

ANS: B Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection (UTI). DIF: Cognitive Level: Apply (application) REF: 1069-1070 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

An older adult male reports to the nurse that he has difficulty starting urination and is voiding several times during the night. The nurse suspects that this client has which condition? A) BPH B) UTI C) Urethral strictures D) Urethritis

ANS: A

The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? a. Heart rate b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level

ANS: B Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

The triage nurse at an ambulatory clinic receives a call from an individual with possible metal fragments in both eyes. Which instructions would the nurse provide for emergency care of this possible eye injury? a. "Remove any visible metal fragments." b. "Apply a loose dressing over your eyes." c. "Rinse your eyes immediately with water." d. "Keep your eyes open to allow tears to form."

b. "Apply a loose dressing over your eyes." An initial intervention for a penetrating eye injury includes covering the eye(s) with a dry, sterile patch and protective shield. The fragments should not be removed by the individual or others. Penetrating eye injuries should not be irrigated (only irrigate for chemical eye injuries).

The nurse is providing care for a patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate? a. "This is often due to an infection that will resolve on its own." b. "Many people experience an age-related decline in their hearing." c. "This is likely an effect of your medications. Try stopping them for a few days." d. "You can likely accommodate for your hearing loss with a few small changes in your routine."

b. "Many people experience an age-related decline in their hearing." Presbycusis is a loss of hearing that is both common and age-related. Infections are most often accompanied by different symptoms. It would be inappropriate to counsel the patient to stop his medications. It would be simplistic to advise the patient to accommodate the hearing loss rather than seek intervention.

When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate? a. "The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." b. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." c. "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." d. "There is a decreased flow of aqueous humor into the anterior chamber by the lens of the eye blocking the papillary opening."

b. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." With primary open-angle glaucoma, there is increased intraocular pressure because the aqueous humor cannot drain from the eye. This leads to damage to the optic nerve over time. Primary angle-closure glaucoma is caused by the lens bulging forward and blocking the flow of aqueous humor into the anterior chamber.

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. A patent arteriovenous fistula (AVF) creates turbulent blood flow that can be assessed by listening for a bruit or palpated for a thrill as the blood passes through the graft. Assessment of neurovascular status in the extremity distal to the graft site is important to determine that the graft does not impair circulation to the extremity but the neurovascular status does not indicate whether the graft is open.

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. A urine specific gravity that is consistently 1.010 and a urine osmolality of about 300 mOsm/kg is the same specific gravity and osmolality as plasma. This indicates that tubules are damaged and unable to concentrate urine. Hematuria is more common with postrenal damage. Tubular damage is associated with a high sodium concentration (greater than 40 mEq/L).

When using the otoscope, the nurse is unable to see the landmarks or light reflex of the tympanic membrane. The tympanic membrane is bulging and red. What does the nurse determine is most likely occurring in the patient's ear? a. Swimmer's ear b. Acute otitis media c. Impacted cerumen d. Chronic otitis media

b. Acute otitis media The manifestations of inability to see the landmarks or light reflex of the tympanic membrane and the bulging and redness of the tympanic membrane are those of acute otitis media. With swimmer's ear and chronic otitis media, there is frequently drainage in the external auditory canal. Impacted cerumen would block the visualization of the tympanic membrane.

In which type of dialysis does the patient dialyze during sleep and leave the fluid in the abdomen during the day? a. Long nocturnal hemodialysis b. Automated peritoneal dialysis (APD) c. Continuous venovenous hemofiltration (CVVH) d. Continuous ambulatory peritoneal dialysis (CAPD)

b. Automated peritoneal dialysis (APD) is the type of dialysis in which the patient dialyzes during sleep and leaves the fluid in the abdomen during the day. Long nocturnal hemodialysis occurs while the patient is sleeping and is done up to six times per week. Continuous venovenous hemofiltration (CVVH) is a type of continuous renal replacement therapy used to treat AKI. Continuous ambulatory peritoneal dialysis (CAPD) is dialysis that is done with exchanges of 1.5 to 3 L of dialysate at least four times daily.

A patient with AKI has a serum potassium level of 6.7 mEq/L (6.7 mmol/L) and the following arterial blood gas results: pH 7.28, PaCO2, 30 mm Hg, PaO2 86 mm Hg, HCO3− 18 mEq/L (18 mmol/L). The nurse recognizes that treatment of the acid-base problem with sodium bicarbonate would cause a decrease in which value? a. pH b. Potassium level c. Bicarbonate level d. Carbon dioxide level

b. During acidosis, potassium moves out of the cell in exchange for H+ ions, increasing the serum potassium level. Correction of the acidosis with sodium bicarbonate will help to shift the potassium back into the cells. A decrease in pH and the bicarbonate and PaCO2 levels would indicate worsening acidosis.

An acoustic neuroma is removed from a patient. The nurse instructs the patient about tumor recurrence. What should the nurse instruct the patient to monitor (select all that apply.)? Select all that apply. a. Lack of coordination b. Episodes of dizziness c. Worsening of hearing d. Inability to close the eye e. Clear drainage from the nose

b. Episodes of dizziness c. Worsening of hearing d. Inability to close the eye An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear nerve (cranial nerve [CN] VIII) enters the internal auditory canal. Clinical manifestations of tumor recurrence including facial nerve (CN VII) paralysis can be manifested by intermittent vertigo, hearing loss, and inability to close the eye. Lack of coordination and clear nasal drainage do not manifest with acoustic neuroma.

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. IV administration of fluid and furosemide (Lasix) Injury is the stage of RIFLE classification when urine output is less than 0.5 mL/kg/hr for 12 hours, the serum creatinine is increased times two or the glomerular filtration rate (GFR) is decreased by 50%. This stage may be reversible by treating the cause or, in this patient, the dehydration by administering IV fluid and a low dose of a loop diuretic, furosemide (Lasix). Assessing the daily weight will be done to monitor fluid changes but it is not the first treatment the nurse should anticipate. IV administration of insulin and sodium bicarbonate would be used for hyperkalemia. Checking the urinalysis will help to determine if the AKI has a prerenal, intrarenal, or postrenal cause by what is seen in the urine but with this patient's dehydration, it is thought to be prerenal to begin treatment.

The patient has a form of glomerular inflammation that is progressing rapidly. She is gaining weight, and the urine output is steadily declining. What is the priority nursing intervention? A.Monitor the patient's cardiac status. B.Teach the patient about hand washing. C.Obtain a serum specimen for electrolytes. D. Increase direct observation of the patient.

b. Monitor the patient's cardiac status The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart, and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions but are not the priority. Electrolyte measurement is a collaborative intervention that will be done as ordered by the health care provider.

To prevent the most common serious complication of PD, what is important for the nurse to do? a. Infuse the dialysate slowly. b. Use strict aseptic technique in the dialysis procedures. c. Have the patient empty the bowel before the inflow phase. d. Reposition the patient frequently and promote deep breathing.

b. Peritonitis is a common complication of peritoneal dialysis (PD) and may require catheter removal and termination of dialysis. Infection occurs from contamination of the dialysate or tubing or from progression of exit-site or tunnel infections and strict sterile technique must be used by health professionals as well as the patient to prevent contamination. Too-rapid infusion may cause shoulder pain and pain may be caused if the catheter tip touches the bowel. Difficulty breathing, atelectasis, and pneumonia may occur from pressure of the fluid on the diaphragm, which may be prevented by elevating the head of the bed and promoting repositioning and deep breathing.

A patient is diagnosed with severe myopia. Which type of correction is the patient planning to have if they state, "I can't wait to be able to see after they implant a contact lens over my lens"? a. Photorefractive keratectomy (PRK) b. Phakic intraocular lenses (phakic IOLs) c. Refractive intraocular lens (refractive IOL) d. Laser-assisted in situ keratomileusis (LASIK)

b. Phakic intraocular lenses (phakic IOLs) Phakic intraocular lenses (phakic IOLs) is the implantation of a contact lens in front of the natural lens. PRK is used with low to moderate amounts of myopia, and the epithelium is removed and the laser sculpts the cornea to correct the refractive error. Refractive IOL is also for patients with a high degree of myopia or hyperopia and involves removing the natural lens and implanting an intraocular lens. LASIK surgery is similar to PRK except that the epithelium is replaced after surgery.

A 68-year-old man with a history of heart failure resulting from hypertension has AKI as a result of the effects of nephrotoxic diuretics. Currently his serum potassium is 6.2 mEq/L (6.2 mmol/L) with cardiac changes, his BUN is 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. This patient has at least three of the six common indications for renal replacement therapy (RRT), including (1) high potassium level, (2) metabolic acidosis, and (3) changed mental status. The other indications are (4) volume overload, resulting in compromised cardiac status (this patient has a history of hypertension), (5) BUN greater than 120 mg/dL, and (6) pericarditis, pericardial effusion, or cardiac tamponade. Although the other treatments may be used, they will not be as effective as RRT for this older patient. Loop diuretics and increased fluid are used if the patient is dehydrated. Insulin and sodium bicarbonate can be used to temporarily drive the potassium into the cells. Sodium polystyrene sulfonate (Kayexalate) is used to actually decrease the amount of potassium in the body.

The nurse is examining a patient's ear in the clinic to determine if recent treatment for acute otitis media has been effective. Which assessment finding indicates resolution of the middle ear infection? a. Fenestrations are visible in the tympanic membrane. b. Tympanic membrane is gray, shiny, and translucent. c. Cone of light is not visible on the tympanic membrane. d. Tympanic membrane is blue and bulging with no landmarks.

b. Tympanic membrane is gray, shiny, and translucent. The tympanic membrane (TM) is normally pearly gray, white or pink, shiny, and translucent. Perforation of the TM that has not healed will appear as open areas of the tympanic membrane. The absence of the cone of light indicates a retracted TM. A bulging red or blue eardrum and lack of landmarks indicates a fluid-filled middle ear. The fluid may be pus or blood.

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

c, e. Because the patient has had nothing to eat or drink for 2 days, she is probably dehydrated and hypovolemic. Decreased cardiac output (CO) is most likely because she is older and takes heart medicine, which is probably for heart failure or hypertension. Both hypovolemia and decreased CO cause prerenal AKI. Anaphylaxis is also a cause of prerenal AKI but is not likely in this situation. Nephrotoxic drugs would contribute to intrarenal causes of AKI and renal calculi would be a postrenal cause of AKI.

The nurse is preparing to administer timolol eye drops for treatment of glaucoma. What statement made by the patient would cause the nurse to hold the medication and report to the health care provider? a. "I have sinusitis." b. "I have migraine headaches a lot." c. "I have chronic obstructive pulmonary disease." d. "I have a history of chronic urinary tract infections."

c. "I have chronic obstructive pulmonary disease." Timolol is a nonselective β-adrenergic blocker that could lead to bronchoconstriction and bronchospasm. For this reason, it should not be used in patients with COPD. Timolol may be used to treat migraine headaches, and it does not affect sinusitis or chronic urinary tract infections.

The nurse is providing discharge teaching to a patient with type 2 diabetes after a scleral buckling procedure. Which statement, if made by the patient, indicates that the discharge teaching is effective? a. "I doubt my other eye will ever be affected." b. "I can expect severe pain after this procedure." c. "I should avoid lifting heavy objects and straining." d. "The procedure will correct my vision immediately."

c. "I should avoid lifting heavy objects and straining." Patients should avoid heavy lifting (more than 20 lb.) and straining. A patient with a detached retina is at risk for detachment of the other retina. Patients usually have little to no discomfort after scleral buckling. Severe, persistent pain should be reported immediately to the health care provider. Vision is restored in about 90% of retinal detachments. Vision will not be restored immediately and takes days to weeks to improve.

A patient on hemodialysis develops a thrombus of a subcutaneous arteriovenous (AV) graft, requiring its removal. While waiting for a replacement graft or fistula, the patient is most likely to have what done for treatment? a. Peritoneal dialysis b. Peripheral vascular access using radial artery c. Silastic catheter tunneled subcutaneously to the jugular vein d. Peripherally inserted central catheter (PICC) line inserted into subclavian vein

c. A more permanent, soft, flexible Silastic double-lumen catheter is used for long-term access when other forms of vascular access have failed. These catheters are tunneled subcutaneously and have Dacron cuffs that prevent infection from tracking along the catheter.

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

c. Continuous renal replacement therapy (CRRT) is indicated for the patient with AKI as an alternative or adjunct to hemodialysis to slowly remove solutes and fluid in the hemodynamically unstable patient. It is especially useful for treatment of fluid overload, but hemodialysis is indicated for treatment of hyperkalemia, pericarditis, or other serious effects of uremia.

What does the dialysate for PD routinely contain? a. Calcium in a lower concentration than in the blood b. Sodium in a higher concentration than in the blood c. Dextrose in a higher concentration than in the blood d. Electrolytes in an equal concentration to that of the blood

c. Dextrose or icodextrin or amino acid is added to dialysate fluid to create an osmotic gradient across the membrane to remove excess fluid from the blood. The dialysate fluid has no potassium so that potassium will diffuse into the dialysate from the blood. Dialysate also usually contains higher calcium to promote its movement into the blood. Dialysate sodium is usually less than or equal to that of blood to prevent sodium and fluid retention.

When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what nursing action would be a priority? a. Recognizing that eye damage caused by glaucoma can be reversed in the early stages b. Giving anticipatory guidance about the eventual loss of central vision that will occur c. Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision d. Managing the pain experienced by patients with glaucoma that persists until the optic nerve atrophies

c. Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision Drug therapy is necessary to prevent the eventual vision loss that may occur as a consequence of glaucoma. For this reason, encourage the patient to remain compliant with drug therapy.

When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? a. Apply pressure to each eyeball for a few seconds after administration. b. Have the patient close the eyes and move them back and forth several times. c. Have the patient put pressure on the inner canthus of the eye after administration. d. Have the patient try to blink out excess medication immediately after administration.

c. Have the patient put pressure on the inner canthus of the eye after administration. Systemic absorption can be minimized by applying pressure to the inner canthus of the eye. The other options will not minimize systemic effects of the medication.

The patient with CKD is brought to the emergency department with Kussmaul respirations. What does the nurse know 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. Kussmaul respirations occur with severe metabolic acidosis when the respiratory system is attempting to compensate by removing carbon dioxide with exhalations. Uremic pleuritis would cause a pleural friction rub. Decreased pulmonary macrophage activity increases the risk of pulmonary infection. Dyspnea would occur with pulmonary edema.

For a patient with CKD the nurse identifies a nursing diagnosis of risk for injury: fracture related to alterations in calcium and phosphorus metabolism. What is the pathologic process directly related to the increased risk for fractures? a. Loss of aluminum through the impaired kidneys b. Deposition of calcium phosphate in soft tissues of the body c. Impaired vitamin D activation resulting in decreased GI absorption of calcium d. Increased release of parathyroid hormone in response to decreased calcium levels

c. The calcium-phosphorus imbalances that occur in CKD result in hypocalcemia, from a deficiency of active vitamin D and increased phosphorus levels. This leads to an increased rate of bone remodeling with a weakened bone matrix. Aluminum accumulation is also believed to contribute to the osteomalacia. Osteitis fibrosa involves replacement of calcium in the bone with fibrous tissue and is primarily a result of elevated levels of parathyroid hormone resulting from hypocalcemia.

During the nursing assessment of the patient with renal insufficiency, the nurse asks the patient specifically about a history of a. angina. b. asthma. c. hypertension. d. rheumatoid arthritis.

c. The most common causes of CKD in the United States are diabetes mellitus and hypertension. The nurse should obtain information on long-term health problems that are related to kidney disease. The other disorders are not closely associated with renal disease.

What causes the gastrointestinal (GI) manifestation of stomatitis in the patient with CKD? a. High serum sodium levels b. Irritation of the GI tract from creatinine c. Increased ammonia from bacterial breakdown of urea d. Iron salts, calcium-containing phosphate binders, and limited fluid intake

c. Uremic fetor, or the urine odor of the breath, is caused by high urea content in the blood. Increased ammonia from bacterial breakdown of urea leads to stomatitis and mucosal ulcerations. Irritation of the gastrointestinal (GI) tract from urea in CKD contributes to anorexia, nausea, and vomiting. Ingestion of iron salts and calcium-containing phosphate binders, limited fluid intake, and limited activity cause constipation.

A patient is recovering from a motor vehicle crash that resulted in blindness. The patient is withdrawn and refuses to get out of bed. What is the nurse's priority goal for this patient? a. Use suitable coping strategies to reduce stress. b. Identify patient's strengths and support system. c. Verbalize feelings related to visual impairment. d. Transition successfully to the sudden vision loss.

c. Verbalize feelings related to visual impairment. The nurse's priority is to help the patient express his feelings about the vision loss resulting from the lack of coping effectively with the situation. Until the patient expresses how they feel, they will be unable to progress in the rehabilitation process.

The nurse is teaching a patient about timolol eye drops for the treatment of glaucoma. What statement made by the patient demonstrates that teaching was effective? a. "I may feel some palpitations after instilling these eye drops." b. "I should withhold this medication if my blood pressure becomes elevated." c. "I should keep my eyes closed for 15 minutes after instilling these eye drops." d. "I may have some temporary blurring of vision after instilling these eye drops."

d. "I may have some temporary blurring of vision after instilling these eye drops." It is common for patients to have a temporary blurring of vision for a few minutes after instilling eye drops. This should not cause concern to the patient. Because timolol is a β-blocker, heart rate may slow, and blood pressure is more likely to decrease if absorbed systemically.

The nurse instructs a patient prescribed dipivefrin eye drops to manage chronic open-angle glaucoma. Which statement, if made by the patient to the nurse, indicates that further teaching is needed? a. "The eye drops could cause a fast heart rate and high blood pressure." b. "I will need to take the eye drops twice a day for at least 2 to 3 months." c. "I may experience eye discomfort and redness from the use of these eye drops." d. "I will apply gentle pressure on the inside corner of my eye after each eye drop."

d. "I will apply gentle pressure on the inside corner of my eye after each eye drop." To avoid systemic reactions such as tachycardia and hypertension, the patient should apply punctual occlusion after instillation of the eye drops. Dipivefrin will control chronic open-angle glaucoma but will not cure the disease. Side effects associated with dipivefrin include ocular discomfort and redness, tachycardia, and hypertension.

The nurse is teaching a patient with glaucoma about administration of pilocarpine. What statement is important for the nurse to include during the instructions? a. "Prolonged eye irritation is an expected adverse effect of this medication." b. "This medication will help to raise intraocular pressure to a near normal level." c. "This medication needs to be continued for at least 5 years after your initial diagnosis." d. "It is important not to do activities requiring visual acuity immediately after administration."

d. "It is important not to do activities requiring visual acuity immediately after administration." Pilocarpine causes blurred vision and difficulty in focusing, so it is important not to engage in any activities requiring visual acuity until the vision clears. It should not cause prolonged eye irritation, and this should be immediately reported to the prescribing care provider. This medication will decrease intraocular pressure.

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 patient with CKD may have unlimited intake of sugars and starches (unless the patient is diabetic) and hard candy is an appropriate snack and may help to relieve the metallic and urine taste that is common in the mouth. Raisins are a high-potassium food. Ice cream contains protein and phosphate and counts as fluid. Pickled foods have high sodium content. Lewis, Sharon L.; Dirksen, Shannon Ruff; Bucher, Linda (2014-03-14). Study Guide for Medical-Surgical Nursing: Assessment and Management of Clinical Problems (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 413). Elsevier Health Sciences. Kindle Edition.

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. Acute tubular necrosis (ATN) is primarily the result of ischemia, nephrotoxins, or sepsis. Major surgery is most likely to cause severe kidney ischemia in the patient requiring a blood transfusion. A blood transfusion hemolytic reaction produces nephrotoxic injury if it occurs. Diabetes mellitus, hypertension, and acetaminophen overdose will not contribute to ATN.

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. As GFR decreases, BUN and serum creatinine levels increase. Although elevated BUN and creatinine indicate that waste products are accumulating, the calculated GFR is considered a more accurate indicator of kidney function than BUN or serum creatinine.

A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing action should be the nurse's priority? a. Teach about visual enhancement techniques. b. Teach nutritional strategies to improve vision. c. Assess coping strategies and support systems. d. Assess impact of vision on normal functioning.

d. Assess impact of vision on normal functioning. The most important nursing intervention is to assess the patient's ability to function with the visual impairment. The nurse will use this information to plan nursing care, including assessment of the patient's coping strategies and teaching about vision enhancement techniques and nutrition.

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. Extensive vascular disease is a contraindication for renal transplantation, primarily because adequate blood supply is essential for the health of the new kidney. Other contraindications include disseminated malignancies, refractory or untreated cardiac disease, chronic respiratory failure, chronic infection, or unresolved psychosocial disorders. Coronary artery disease (CAD) may be treated with bypass surgery before transplantation and transplantation can relieve hypertension. Hepatitis B or C infection is not a contraindication.

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. In prerenal oliguria, the oliguria is caused by a decrease in circulating blood volume and there is no damage yet to the renal tissue. It can be reversed by correcting the precipitating factor, such as fluid replacement for hypovolemia. Prerenal oliguria is characterized by urine with a high specific gravity and a low sodium concentration, whereas oliguria of intrarenal failure is characterized by urine with a low specific gravity and a high sodium concentration. Malignant hypertension causes damage to renal tissue and intrarenal oliguria.

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 may cause seizures. d. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calcium levels are increased.

d. In the patient with CKD, when serum calcium levels are increased, calcium-based phosphate binders are not used. The nutrient supplemented for patients on dialysis is folic acid. The various body system manifestations occur with uremia, which includes azotemia. Meperidine is contraindicated in patients with CKD related to possible seizures.

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. Measuring daily weights with the same scale at the same time each day allows for the evaluation and detection of excessive body fluid gains or losses. Infection is the leading cause of death in AKI, so meticulous aseptic technique is critical. The fluid limitation in the oliguric phase is 600 mL plus the prior day's measured fluid loss. Dietary sodium and potassium intake are managed according to the plasma levels.

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. The blood urea nitrogen (BUN) and creatinine levels remain high during the oliguric and diuretic phases of AKI. The recovery phase begins when the glomerular filtration returns to a rate at which BUN and creatinine stabilize and then decrease. Urinary output of 3 to 5 L/ day, decreasing sodium and potassium levels, and fluid weight loss are characteristic of the diuretic phase of AKI.

A patient is scheduled for a corneal transplant and is concerned regarding the difficulty with vision that may last for up to 12 months after the transplant. What is the best response by the nurse? a. If the transplant is done soon after the donor dies, there will not be as much trouble recovering vision. b. The astigmatism the patient is experiencing may be corrected with glasses or rigid contact lenses. c. Increasing the amount of light and using a magnifier to read will be helpful if a transplant is not wanted. d. There are newer procedures in which only the damaged cornea epithelial layer is replaced, and they have a faster recovery.

d. There are newer procedures in which only the damaged cornea epithelial layer is replaced, and they have a faster recovery. The new procedures are called Descemet's stripping endothelial keratoplasty (DSEK) and Descemet's membrane endothelial keratoplasty (DMEK). Corneal transplants should be done as soon as possible, but this does not affect the rate of visual recovery. Astigmatism is not experienced with corneal scars and opacities requiring a corneal transplant. Increasing light and magnification helps a person with cataracts to read.

A patient with septic shock is receiving multiple medications. Which intravenous (IV) medication is most likely to cause a hearing loss? a. Dopamine b. Ampicillin c. Aspirin d. Vancomycin

d. Vancomycin The IV medication in use that is most likely to cause a hearing loss is vancomycin (Vancocin) because it is an ototoxic medication. For that reason, serum drug levels are monitored to maintain therapeutic levels and reduce the risk of ototoxicity. Aspirin can also cause hearing loss, but it is not administered IV. Neither dopamine nor ampicillin is likely to cause hearing loss.

A nurse receives a triage call from a client with newly diagnosed heart failure. Which statement indicates a worsening of the​ client's condition? ​"I've had two episodes of diarrhea this past​ week." ​"I'm eating 6 small meals a day​ now." ​"I've gained 3 pounds in 24​ hours." ​"I'm most comfortable sleeping with 2​ pillows."

​"I've gained 3 pounds in 24​ hours." Rationale: Heart failure is a condition where the heart is unable to pump enough blood into circulation to meet the​ body's demands. When the heart is unable to eliminate extra fluid and wastes from the​ body, those fluids accumulate in the​ body, making the heart work harder. A weight gain of 3 pounds in 24 hours is approximately 1.3 liters of fluid and an indication of fluid volume retention. A client with heart failure would be expected to sleep with pillows to facilitate breathing. Two episodes of diarrhea in a week is not related to heart failure and not an indication of a worsening condition. Six small meals per day are encouraged to facilitate nutrition and consume energy.

A nurse is on orientation in the coronary care unit​ (CCU) and learning about the​ Frank-Starling mechanism. Which statement by the nurse is​ correct? ​"The less the heart fills with​ blood, the stronger the force of cardiac​ contraction." ​"The more the heart fills with​ blood, the weaker the force of cardiac​ contraction." ​"The Frank-Starling mechanism has no effect on the​ heart, only on the cardiac​ vessels." ​"The more the heart fills with​ blood, the stronger the force of cardiac​ contraction."

​"The more the heart fills with​ blood, the stronger the force of cardiac​ contraction."

Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)? a. Ask a patient with decreased visual acuity about medications taken at home. b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. c. Obtain information from a patient about any history of childhood ear infections. d. Inspect a patient's external ear for redness, swelling, or presence of skin lesions.

ANS: B The Snellen test does not require nursing judgment and is appropriate to delegate to UAP who have been trained to perform it. History taking about infection or medications and assessment are actions that require critical thinking and should be done by the RN.

The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction? a. Apply antibiotic drops to the eye several times daily. b. Wash hands frequently and avoid touching the eyes. c. Apply a new occlusive dressing to the affected eye at bedtime. d. Use corticosteroid ophthalmic ointment to decrease inflammation.

ANS: B The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications

The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction? a. Apply antibiotic drops to the eye several times daily. b. Wash hands frequently and avoid touching the eyes. c. Apply a new occlusive dressing to the affected eye at bedtime. d. Use corticosteroid ophthalmic ointment to decrease inflammation.

ANS: B The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications.

A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8-hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is <30 mL/min/1.73m2.

ANS: B The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider? a. Serum creatinine level 2.1 mg/dL b. Serum potassium level 6.5 mEq/L c. White blood cell count 11,500/µL d. Blood urea nitrogen (BUN) 56 mg/dL

ANS: B The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately. The nurse also will report the other laboratory values, but abnormalities in these are not immediately life threatening.

A 27-yr-old patient who has testicular cancer is being admitted for a unilateral orchiectomy. The patient does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is appropriate for the nurse to take? a. Teach the patient and the wife that impotence is unlikely after unilateral orchiectomy. b. Ask the patient if he has any questions or concerns about the diagnosis and treatment. c. Inform the patient's wife that concerns about sexual function are common with this diagnosis. d. Document the patient's lack of communication on the health record and continue preoperative care.

ANS: B The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, the nurse should not offer teaching about complications after orchiectomy. Documentation of the patient's lack of interaction is not an adequate nursing action in this situation. DIF: Cognitive Level: Apply (application) REF: 1280 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Complaint of flank pain b. Blood pressure 90/48 mm Hg c. Cloudy and foul-smelling urine d. Temperature 100.1° F (57.8° C)

ANS: B The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis. DIF: Cognitive Level: Apply (application) REF: 1069 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis? Which initial response by the nurse is best? a. "It depends on which type of dialysis you are considering." b. "Tell me more about what you are thinking regarding dialysis." c. "You are the only one who can make the decision about dialysis." d. "Many people your age use dialysis and have a good quality of life."

ANS: B The nurse should initially clarify the patient's concerns and questions about dialysis. The patient is the one responsible for the decision and many people using dialysis do have good quality of life, but these responses block further assessment of the patient's concerns. Referring to which type of dialysis the patient might use only indirectly responds to the patient's question

A patient with benign prostatic hyperplasia (BPH) is admitted to the hospital with urinary retention and new-onset elevations in the blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first? a. Schedule an abdominal computed tomography (CT) scan. b. Insert a coude urinary catheter. c. Draw blood for a complete blood count. d. Infuse normal saline at 50 mL/hr.

ANS: B The patient data indicate that the patient may have acute renal failure caused by the BPH. The initial therapy will be to insert a catheter. The other actions also are appropriate, but they can be implemented after the acute urinary retention is resolved.

The nurse will plan to teach the patient scheduled for photovaporization of the prostate (PVP) a. that urine will appear bloody for several days. b. how to care for an indwelling urinary catheter. c. that symptom improvement takes 2 to 3 weeks. d. about complications associated with urethral stenting.

ANS: B The patient will have an indwelling catheter for 24 to 48 hours and will need teaching about catheter care. There is minimal bleeding with this procedure. Symptom improvement is almost immediate after PVP. Stent placement is not included in the procedure. DIF: Cognitive Level: Apply (application) REF: 1272 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 56-year-old female patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect? a. Poor skin turgor b. Recent weight gain c. Elevated urine ketones d. Decreased blood pressure

ANS: B The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. DIF: Cognitive Level: Understand (comprehension) REF: 1075-1076 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about a. tympanometry. b. rotary chair testing. c. pure-tone audiometry. d. bone-conduction testing.

ANS: B The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing.

A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing, and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is most appropriate at this time? a. Grieving related to current loss of functional vision b. Anxiety related to the possibility of permanent vision loss c. Situational low self-esteem related to loss of visual function d. Risk for falls related to inability to see environmental hazards

ANS: B The patient's restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact. There is no indication of impaired self-esteem at this time

A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing, and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is most appropriate at this time? a. Grieving related to current loss of functional vision b. Anxiety related to the possibility of permanent vision loss c. Situational low self-esteem related to loss of visual function d. Risk for falls related to inability to see environmental hazards

ANS: B The patient's restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact. There is no indication of impaired self-esteem at this time.

A patient tells the nurse that he decided to seek treatment for erectile dysfunction (ED) because his wife "is losing patience with the situation." The nurse's follow-up questions should focus on the man's identified concern with a. low self-esteem. c. increased anxiety. b. role performance. d. infrequent intercourse.

ANS: B The patient's statement indicates that the relationship with his wife is his primary concern. Although anxiety, low self-esteem, and ineffective sexuality patterns may also be concerns, the patient information suggests that addressing the role performance problem will lead to the best outcome for this patient. DIF: Cognitive Level: Apply (application) REF: 1288 TOP: Nursing Process: Intervention MSC: NCLEX: Psychosocial Integrity

A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the stoma and requests that only the ostomy nurse specialist does the stoma care. The nurse identifies a nursing diagnosis of a. anxiety related to effects of procedure on lifestyle. b. disturbed body image related to change in function. c. readiness for enhanced coping related to need for information. d. self-care deficit, toileting, related to denial of altered body function.

ANS: B The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient. The patient does not appear to be ready for enhanced coping. The patient's insistence that only the ostomy nurse care for the stoma indicates that denial is not present. DIF: Cognitive Level: Apply (application) REF: 1098 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

The nurse assessing the urinary system of a 45-year-old female would use auscultation to a. determine kidney position. b. identify renal artery bruits. c. check for ureteral peristalsis. d. assess for bladder distention.

ANS: B The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal aortic aneurysm. Auscultation would not be helpful in assessing for the other listed urinary tract information. DIF: Cognitive Level: Understand (comprehension) REF: 1055 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: B The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a. Administer the ordered analgesic. b. Check the patient's oxygen saturation. c. Examine the eye for evidence of trauma. d. Assess each of the cranial nerve functions.

ANS: B The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take

The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. The nurse will need to intervene if the student a. pulls the auricle of the ear up and posterior. b. chooses a speculum larger than the ear canal. c. stabilizes the hand holding the otoscope on the patient's head. d. stops inserting the otoscope after observing impacted cerumen.

ANS: B The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination.

Which information will the nurse plan to include when teaching a young adult who has a family history of testicular cancer about testicular self-examination? a. Testicular self-examination should be done at least weekly. b. Testicular self-examination should be done in a warm room. c. The only structure normally felt in the scrotal sac is the testis. d. Call the health care provider if one testis is larger than the other.

ANS: B The testes will hang lower in the scrotum when the temperature is warm (e.g., during a shower), and it will be easier to palpate. The epididymis is also normally palpable in the scrotum. One testis is normally larger. Men at high risk should perform testicular self-examination monthly. DIF: Cognitive Level: Understand (comprehension) REF: 1286 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

Which action will the nurse anticipate taking for an otherwise healthy 50-year-old who has just been diagnosed with Stage 1 renal cell carcinoma? a. Prepare patient for a renal biopsy. b. Provide preoperative teaching about nephrectomy. c. Teach the patient about chemotherapy medications. d. Schedule for a follow-up appointment in 3 months.

ANS: B The treatment of choice in patients with localized renal tumors who have no co-morbid conditions is partial or total nephrectomy. A renal biopsy will not be needed in a patient who has already been diagnosed with renal cancer. Chemotherapy is used for metastatic renal cancer. Because renal cell cancer frequently metastasizes, treatment will be started as soon as possible after the diagnosis

A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will a. have the patient empty the bladder completely, then obtain the next urine specimen that the patient is able to void. b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. c. insert a short sterile "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen. d. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container.

ANS: B This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, "insert a short, small, 'mini' catheter attached to a collecting container" describes a technique that would result in a sterile specimen, but a health care provider's order for a catheterized specimen would be required. Using Betadine before obtaining the specimen is not necessary, and might result in suppressing the growth of some bacteria. The technique described in the answer beginning "have the patient empty the bladder completely" would not result in a sterile specimen. DIF: Cognitive Level: Apply (application) REF: 1057 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When caring for a patient with continuous bladder irrigation after having transurethral resection of the prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Teach the patient how to perform Kegel exercises. b. Report any complaints of pain or spasms to the nurse. c. Monitor for increases in bleeding or presence of clots. d. Increase the flow rate of the irrigation if clots are noted.

ANS: B UAP education and role includes reporting patient concerns to supervising nurses. Patient teaching, assessments for complications, and actions such as bladder irrigation require more education and should be done by licensed nursing staff. DIF: Cognitive Level: Apply (application) REF: 1274 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Evaluate a patient's ability to administer eye drops. b. Use a Snellen chart to check a patient's visual acuity. c. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D. d. Check the patient's external ear for signs of irritation caused by a hearing aid.

ANS: B Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice

Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Evaluate a patient's ability to administer eye drops. b. Use a Snellen chart to check a patient's visual acuity. c. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D. d. Check the patient's external ear for signs of irritation caused by a hearing aid.

ANS: B Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice.

Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene immediately? a. UAP raise the side rails on the bed. b. UAP turn on the patient's television. c. UAP turn the patient to the right side. d. UAP place an emesis basin at the bedside.

ANS: B Watching television may exacerbate the symptoms of an acute attack of Ménière's disease. The other actions are appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack.

A blind client is admitted to the hospital unit. Orientation to the unit includes which information? (Select all that apply.) a. Introduce the staff to the client. b. Describe the room to the client using one reference point. c. Walk the client to the bathroom and describe it. d. Tell the client to use the call light if he or she wants to go to the bathroom. e. Explain the routine of the unit and how to operate the bed controls. f. Assist in putting the client's belongings away.

ANS: B, C, E, F The client needs to know where everything is located to be independent and safe from falls. Clients need to be shown where things are and how to do things such as turn on the call light and raise the head of the bed. The client should be introduced to the staff, not the reverse, and should first be shown how to use the call light.

A patient has been diagnosed with urinary tract calculi that are high in uric acid. Which foods will the nurse teach the patient to avoid (select all that apply)? a. Milk b. Liver c. Spinach d. Chicken e. Cabbage f. Chocolate

ANS: B, D Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones. DIF: Cognitive Level: Understand (comprehension) REF: 1080 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse is caring for a client immediately following a transurethral prostatectomy (TURP). The nurse places high priority on which nursing interventions in the immediate post-op period for this client? Select all that apply. A) Asses for signs of a UTI B) Prevent post-op atelectasis C) Discontinue urinary catheter asap D) Adjust flow rate of the bladder irrigant to keep catheter patent E) Monitor the amount of blood in the urine

ANS: B, D, E

The nurse taking a focused health history for a patient with possible testicular cancer will ask the patient about a history of a. testicular torsion. b. testicular trauma. c. undescended testicles. d. sexually transmitted infection (STI).

ANS: C Cryptorchidism is a risk factor for testicular cancer if it is not corrected before puberty. STI, testicular torsion, and testicular trauma are risk factors for other testicular conditions but not for testicular cancer. DIF: Cognitive Level: Understand (comprehension) REF: 1284 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take first? a. Notify the patient's health care provider. b. Teach correct midstream urine collection. c. Ask the patient about current medications. d. Question the patient about urinary tract infection (UTI) risk factors.

ANS: C A red-orange color in the urine is normal with some over-the-counter (OTC) medications such as phenazopyridine (Pyridium). The color would not be expected with urinary tract infection, is not a sign that poor technique was used in obtaining the specimen, and does not need to be communicated to the health care provider until further assessment is done. DIF: Cognitive Level: Apply (application) REF: 1052 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 51-year-old man is scheduled for an annual physical exam at the outpatient clinic. The nurse will plan to teach the patient about the purpose of a. urinalysis collection. b. uroflowmetry studies. c. prostate specific antigen (PSA) testing. d. transrectal ultrasound scanning (TRUS).

ANS: C An annual digital rectal exam (DRE) and PSA are recommended starting at age 50 for men who have an average risk for prostate cancer. Urinalysis and uroflowmetry studies are done if patients have symptoms of urinary tract infection or changes in the urinary stream. TRUS may be ordered if the DRE or PSA are abnormal.

A 53-yr-old patient is scheduled for an annual physical examination. The nurse will plan to teach the patient about the purpose of a. urinalysis collection. b. uroflowmetry studies. c. prostate specific antigen (PSA) testing. d. transrectal ultrasound scanning (TRUS).

ANS: C An annual digital rectal exam (DRE) and PSA are usually recommended starting at age 50 years for men who have an average risk for prostate cancer. Urinalysis and uroflowmetry studies are done if patients have symptoms of urinary tract infection or changes in the urinary stream. TRUS may be ordered if the DRE or PSA results are abnormal. DIF: Cognitive Level: Apply (application) REF: 1273 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is most appropriate? a. Monitor the patient's intake and output over night. b. Have the patient drink small amounts of fluid frequently. c. Use an ultrasound scanner to check the postvoiding residual volume. d. Reassure the patient that this is normal after rectal surgery because of anesthesia.

ANS: C An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis and discomfort from a full bladder if the nurse waits to address the problem for several hours. DIF: Cognitive Level: Apply (application) REF: 1088 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which statement made by a client after corneal transplantation indicates a need for further teaching? a. "I will wear an eye shield at night for at least 1 month." b. "I will avoid bending at the waist and straining when moving my bowels." c. "I won't worry if I have increased tearing, because it is normal." d. "I'll notify the ophthalmologist if any signs of rejection occur."

ANS: C Aqueous humor can leak from the incision site if wound closure is incomplete. Any fluid coming from the eye in the early postoperative period needs to be checked by the provider.

Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? a. Postural hypotension b. Recurrent tachycardia c. Knee and hip joint pain d. Increased serum creatinine

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

A nurse should instruct a patient with recurrent staphylococcal and seborrheic blepharitis to a. irrigate the eyes with saline solution. b. apply cool compresses to the eyes three times daily. c. use a gentle baby shampoo to clean the lids as needed. d. schedule an appointment for surgical removal of the lesion.

ANS: C Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder.

A 28-year-old male patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time? a. Complications of renal transplantation b. Methods for treating severe chronic pain c. Discussion of options for genetic counseling d. Differences between hemodialysis and peritoneal dialysis

ANS: C Because a 28-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain. DIF: Cognitive Level: Apply (application) REF: 1083 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

A 46-year-old female patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take? a. Teach the patient to take the prescribed Bactrim for 3 more days. b. Remind the patient about the need to drink 1000 mL of fluids daily. c. Obtain a midstream urine specimen for culture and sensitivity testing. d. Suggest that the patient use acetaminophen (Tylenol) to treat the symptoms.

ANS: C Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter (OTC) medications such as phenazopyridine (Pyridium) in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with Bactrim, the patient is likely to need a different antibiotic. DIF: Cognitive Level: Apply (application) REF: 1067 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which assessment finding alerts the nurse to provide patient teaching about cataract development? a. History of hyperthyroidism b. Unequal pupil size and shape c. Blurred vision and light sensitivity d. Loss of peripheral vision in both eyes

ANS: C Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is indicative of anisocoria, not cataracts. Loss of peripheral vision is a sign of glaucoma.

Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider? a. The patient is voiding every 4 hours. b. The patient is using opioids for pain. c. The patient has seen clots in the urine. d. The patient is anxious about the cancer.

ANS: C Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure. DIF: Cognitive Level: Apply (application) REF: 1086 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which information about a patient with Goodpasture syndrome requires the most rapid action by the nurse? a. Blood urea nitrogen level is 70 mg/dL. b. Urine output over the last 2 hours is 30 mL. c. Audible crackles bilaterally over the posterior chest to the midscapular level. d. Elevated level of antiglomerular basement membrane (anti-GBM) antibodies.

ANS: C Crackles heard to a high level indicate a need for rapid actions such as assessment of oxygen saturation, reporting the findings to the health care provider, initiating oxygen therapy, and dialysis. The other findings will also be reported, but are typical of Goodpasture syndrome and do not require immediate nursing action.

A patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because it might affect his ability to have sexual intercourse. Which action should the nurse take? a. Discuss alternative methods of sexual expression. b. Teach about medication for erectile dysfunction (ED). c. Clarify that TURP does not commonly affect erection. d. Offer reassurance that fertility is not affected by TURP.

ANS: C ED is not a concern with TURP, although retrograde ejaculation is likely, and the nurse should discuss this with the patient. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns. DIF: Cognitive Level: Apply (application) REF: 1272 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A client diagnosed with early prostate cancer is confused that surgery has not been planned. Which is the nurse's best response? a. "The disease is slow-growing. The risks of surgery at your age are not justified by the outcome." b. "Your disease is so advanced that surgery at this point would not increase your chances of cure." c. "Your disease is in a very early stage and is slow-growing. Your doctor will monitor you." d. "This stage indicates that you do not really have cancer, so surgery is not necessary."

ANS: C Early prostate cancer may have no clinical manifestations and may be found on a routine physical. It is slow-growing and may never become a problem for the client. Close follow-up (or watchful waiting) is the common prescription for this stage unless the client experiences symptoms. Telling the client that surgery is not justified, or that the cancer is too advanced at this point, and stating that he does not have cancer are inaccurate statements.

Which information will the nurse teach a patient who has chronic prostatitis? a. Ibuprofen (Motrin) should provide good pain control. b. Prescribed antibiotics should be taken for 7 to 10 days. c. Intercourse or masturbation will help relieve symptoms. d. Cold packs used every 4 hours will decrease inflammation.

ANS: C Ejaculation helps drain the prostate and relieve pain. Warm baths are recommended to reduce pain. Nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed but usually do not offer adequate pain relief. Antibiotics for chronic prostatitis are taken for 4 to 12 weeks. DIF: Cognitive Level: Apply (application) REF: 1283 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with a. antibiotics. b. antifungals. c. anticoagulants. d. antihypertensives.

ANS: C Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure. DIF: Cognitive Level: Apply (application) REF: 1082 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication? a. Creatinine 1.6 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

ANS: C High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered.

The nurse determines that further instruction is needed for a patient with interstitial cystitis when the patient says which of the following? a. "I should stop having coffee and orange juice for breakfast." b. "I will buy calcium glycerophosphate (Prelief) at the pharmacy." c. "I will start taking high potency multiple vitamins every morning." d. "I should call the doctor about increased bladder pain or odorous urine."

ANS: C High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching. DIF: Cognitive Level: Apply (application) REF: 1072 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient passing bloody urine is scheduled for a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate? a. "Your doctor will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys." b. "Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney." c. "Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray." d. "Your doctor will inject a radioactive solution into a vein in your arm and the distribution of the isotope in your kidneys and bladder will be checked."

ANS: C In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken. The response beginning, "Your doctor will place a catheter" describes a renal arteriogram procedure. The response beginning, "Your doctor will inject a radioactive solution" describes a nuclear scan. The response beginning, "Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted" describes a retrograde pyelogram. DIF: Cognitive Level: Apply (application) REF: 1059 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? a. "I will apply the eardrops to the cotton wick in the ear canal." b. "I can use aspirin or acetaminophen (Tylenol) for pain relief." c. "I will clean the ear canal daily with a cotton-tipped applicator." d. "I can use warm compresses to the outside of the ear for comfort."

ANS: C Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful

A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment? a. "I use aspirin when I have a sinus headache." b. "I have had frequent episodes of conjunctivitis." c. "I take metoprolol (Lopressor) daily for angina." d. "I have not had an eye examination for 10 years."

ANS: C It is important to note whether the patient takes any -adrenergic blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.

The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to a. obtain more information about the cause of the patient's vision loss. b. obtain information from the spouse about the patient's special needs. c. make eye contact with the patient and ask about any need for assistance. d. perform an evaluation of the patient's visual acuity using a Snellen chart.

ANS: C Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions. The patient (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the patient's visual acuity are not priorities during the initial assessment

The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to a. obtain more information about the cause of the patient's vision loss. b. obtain information from the spouse about the patient's special needs. c. make eye contact with the patient and ask about any need for assistance. d. perform an evaluation of the patient's visual acuity using a Snellen chart.

ANS: C Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions. The patient (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the patient's visual acuity are not priorities during the initial assessment.

Which clinical manifestation alerts the nurse to the possibility of a vitreous humor hemorrhage? a. Presence of a red reflex b. Reddened whites of the eye c. Red haze or floaters in the line of vision d. Swelling of the upper and lower eyelids

ANS: C Mild seepage of blood into the vitreous humor causes the client's vision to have an overall red haze or floaters. With a vitreous humor hemorrhage, the red reflex is reduced. Reddened whites of the eye and swelling of the eyelids would indicate irritation and infection of the eye.

A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care? a. Demonstrate the use of the Credé maneuver. b. Teach exercises to strengthen the pelvic floor. c. Place a bedside commode close to the patient's bed. d. Use an ultrasound scanner to check postvoiding residuals.

ANS: C Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence. DIF: Cognitive Level: Apply (application) REF: 1088 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is most important to report to the health care provider at this time? a. The patient has had blurred vision for 3 years. b. The patient has not eaten anything for 8 hours. c. The patient takes 2 antihypertensive medications. d. The patient gets nauseated with general anesthesia.

ANS: C Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO for 6 to 8 hours before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia

27. The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is most important to report to the health care provider at this time? a. The patient has had blurred vision for 3 years. b. The patient has not eaten anything for 8 hours. c. The patient takes 2 antihypertensive medications. d. The patient gets nauseated with general anesthesia.

ANS: C Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO for 6 to 8 hours before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia.

A client is using an ophthalmic beta-blocking agent for the treatment of glaucoma. Which instruction does the nurse give to the client to prevent orthostatic hypotension? a. "Change positions quickly after administering the drops." b. "Take your pulse at least four times daily." c. "Apply pressure to the inside corner of your eye when administering the drops." d. "Lay down for 10 minutes after administering the drops."

ANS: C Nasal punctal occlusion during eyedrop instillation keeps the drug in contact with the eye structures longer and decreases systemic absorption and side effects. Systemic distribution of the drug is what may cause orthostatic hypotension. The other answers will not help prevent orthostatic hypotension.

Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a higher-pitched tone of voice to provide instructions. c. Ask for permission to turn off the television before teaching d. Wait until family members have left before initiating teaching.

ANS: C Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high-pitched tones is lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until family members have left to provide patient teaching

A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. Unlimited fluids are allowed because retained fluid is removed during dialysis. c. More protein is allowed because urea and creatinine are removed by dialysis. d. Dietary potassium is not restricted because the level is normalized by dialysis.

ANS: C Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention? a. The LPN/LVN administers the erythropoietin subcutaneously. b. The LPN/LVN assists the patient to ambulate out in the hallway. c. The LPN/LVN administers the iron supplement and phosphate binder with lunch. d. The LPN/LVN carries a tray containing low-protein foods into the patient's room.

ANS: C Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency.

Which action by the unlicensed assistive personnel (UAP) who are assisting with the care of male patients with reproductive problems indicates that the nurse should provide more teaching? a. The UAP apply a cold pack to the scrotum for a patient with mumps orchitis. b. The UAP help a patient who has had a prostatectomy to put on antiembolism hose. c. The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter. d. The UAP encourage a high oral fluid intake for patient who had transurethral resection of the prostate yesterday.

ANS: C Paraphimosis can be caused by failing to replace the foreskin back over the glans after cleaning. The other actions by UAP are appropriate. DIF: Cognitive Level: Apply (application) REF: 1274 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: C Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics. DIF: Cognitive Level: Apply (application) REF: 1094 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I have to sleep with the television on." Which follow-up question is most appropriate to obtain more information about possible hearing problems? a. "Do you grind your teeth at night?" b. "What time do you usually fall asleep?" c. "Have you noticed ringing in your ears?" d. "Are you ever dizzy when you are lying down?"

ANS: C Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses "Do you grind your teeth at night?" and "Are you ever dizzy when you are lying down?" would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint (TMJ) pain. The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patient's ears.

A 63-year-old male patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the physician? a. Cloudy appearing urine b. Hypotonic bowel sounds c. Heart rate 102 beats/minute d. Continuous stoma drainage

ANS: C Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal

The nurse is obtaining the pertinent health history for a man who is being evaluated for infertility. Which question focuses on a possible cause of infertility? a. "Are you circumcised?" b. "Have you had surgery for phimosis?" c. "Do you use medications to improve muscle mass?" d. "Is there a history of prostate cancer in your family?"

ANS: C Testosterone or testosterone-like medications may adversely affect sperm count. The other information will be obtained in the health history but does not affect the patient's fertility. DIF: Cognitive Level: Apply (application) REF: 1289 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. blood in the urine. . b. lower back or hip pain. c. force of urinary stream d. erectile dysfunction (ED).

ANS: C The American Urological Association Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, and so on. Blood in the urine, ED, and back or hip pain are not typical symptoms of BPH. DIF: Cognitive Level: Apply (application) REF: 1268 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)? a. Teach the patient about use of medications to reduce symptoms. b. Place the patient in a dark, quiet room to avoid stimulating BPPV attacks. c. Teach the patient that canalith repositioning may be used to reduce dizziness. d. Speak slowly and in a low-pitch to ensure that the patient is able to hear instructions.

ANS: C The Epley maneuver is used to reposition "ear rocks" in BPPV. Medications and placement in a dark room may be used to treat Ménière's disease, but are not necessary for BPPV. There is no hearing loss with BPPV.

A 68-year-old male patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching? a. Application of ostomy appliances b. Barrier products for skin protection c. Catheterization technique and schedule d. Analgesic use before emptying the pouch

ANS: C The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful. DIF: Cognitive Level: Apply (application) REF: 1097 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine output b. Calcium level c. Cardiac rhythm d. Neurologic status

ANS: C The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate.

ANS: B The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

ANS: C The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate.

After a ureterolithotomy, a female patient has a left ureteral catheter and a urethral catheter in place. Which action will the nurse include in the plan of care? a. Provide teaching about home care for both catheters. b. Apply continuous steady tension to the ureteral catheter. c. Call the health care provider if the ureteral catheter output drops suddenly. d. Clamp the ureteral catheter off when output from the urethral catheter stops.

ANS: C The health care provider should be notified if the ureteral catheter output decreases because obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided in order to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Because the patient is not usually discharged with a ureteral catheter in place, patient teaching about both catheters is not needed. DIF: Cognitive Level: Apply (application) REF: 1093-1095 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which information from a patient's urinalysis requires that the nurse notify the health care provider? a. pH 6.2 b. Trace protein c. WBC 20 to 26/hpf d. Specific gravity 1.021

ANS: C The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation. The other findings are normal. DIF: Cognitive Level: Apply (application) REF: 1062 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Check the medical record for most recent potassium level. d. Check the chart for the patient's current creatinine level.

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

A 32-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider? a. Infuse 5% dextrose in normal saline at 75 mL/hr. b. Order regular diet after patient is awake and alert. c. Give ketorolac (Toradol) 10 mg PO PRN for pain. d. Draw blood urea nitrogen (BUN) and creatinine in 2 hours.

ANS: C The nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.

To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement? a. Arrange to include otoscopic examinations for all patients. b. Administer influenza immunizations to all students at the clinic. c. Discuss the importance of limiting exposure to amplified music. d. Perform tympanometry on all patients between the ages of 18 to 24.

ANS: C The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients

To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement? a. Arrange to include otoscopic examinations for all patients. b. Administer influenza immunizations to all students at the clinic. c. Discuss the importance of limiting exposure to amplified music. d. Perform tympanometry on all patients between the ages of 18 to 24.

ANS: C The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients.

When preparing a female patient with bladder cancer for intravesical chemotherapy, the nurse will teach about a. premedicating to prevent nausea. b. obtaining wigs and scarves to wear. c. emptying the bladder before the medication. d. maintaining oral care during the treatments.

ANS: C The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not usually experienced with intravesical chemotherapy. DIF: Cognitive Level: Apply (application) REF: 1086 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to get most of my protein from low-fat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take erythropoietin to boost my immune system and help prevent infection."

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

After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Teach the patient about normal AVG function. b. Remind the patient to take a daily low-dose aspirin tablet. c. Report the patient's symptoms to the health care provider. d. Elevate the patient's arm on pillows to above the heart level.

ANS: C The patient's complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

The plan of care for a patient immediately after a perineal radical prostatectomy will include decreasing the risk for infection related to a. urinary incontinence. c. fecal wound contamination. b. prolonged urinary stasis. d. suprapubic catheter placement.

ANS: C The perineal approach increases the risk for infection because the incision is located close to the anus, and contamination with feces is possible. Urinary stasis and incontinence do not occur because the patient has a retention catheter in place for 1 to 2 weeks. A urethral catheter is used after the surgery. DIF: Cognitive Level: Apply (application) REF: 1278 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When teaching a patient who is scheduled for a transurethral resection of the prostate (TURP) about continuous bladder irrigation, which information will the nurse include? a. Bladder irrigation decreases the risk of postoperative bleeding. b. Hydration and urine output are maintained by bladder irrigation. c. Bladder irrigation prevents obstruction of the catheter after surgery. d. Antibiotics are infused on a continuous basis with bladder irrigation.

ANS: C The purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or improve hydration. Antibiotics are given by the IV route, not through the bladder irrigation.

A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? a. Suggest the patient arrange a ride to the clinic immediately. b. Ask about the presence of "floaters" in the patient's visual field. c. Remind the patient it may take months to restore vision after transplant. d. Teach the patient to continue using prescribed pupil-dilating medications.

ANS: C Vision may not be restored for up to a year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because "floaters" are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant surgery.

A client has undergone creation of an ileal conduit. Which instruction to the client about urostomy care would be appropriate to include in the teaching plan? A) Cut the faceplate of the appliance so that the opening is slightly smaller than the stoma B) Plan to do appliance changes just before bedtime C) Limit fluids to minimize odor from urine breakdown to ammonia D) Cleanse the skin around the stoma using gentle soap and water, rinse and dry well

ANS: D

The nurse is teaching a female client with recurrent cystitis who is scheduled for cystoscopy in the morning. Which preprocedure instructions should the nurse include in the teaching? A) Take Tylenol and Benadryl the morning of the test to minimize allergic reaction B) Light breakfast may be eaten C) This test is only used to diagnose disorders D) Take a laxative the evening before procedure

ANS: D

The nurse teaches a 64-year-old woman to prevent the recurrence of renal calculi by a. using a filter to strain all urine. b. avoiding dietary sources of calcium. c. choosing diuretic fluids such as coffee. d. drinking 2000 to 3000 mL of fluid a day.

ANS: D A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones. DIF: Cognitive Level: Apply (application) REF: 1081 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse performing an eye examination will document normal findings for accommodation when a. shining a light into the patient's eye causes pupil constriction in the opposite eye. b. a blink reaction follows touching the patient's pupil with a piece of sterile cotton. c. covering one eye for 1 minute and noting pupil constriction as the cover is removed. d. the pupils constrict while fixating on an object being moved closer to the patient's eyes.

ANS: D Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object being moved far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation.

Which statement by the patient to the home health nurse indicates a need for more teaching about self-administering eardrops? a. "I will leave the ear wick in place while administering the drops." b. "I should lie down before and for 5 minutes after administering the drops." c. "I will hold the tip of the dropper above the ear while administering the drops." d. "I should keep the medication refrigerated until I am ready to administer the drops."

ANS: D Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate

An older adult client who has a mature cataract in the right eye states, "Now I have lost the sight in my right eye because I waited too long for treatment." How does the nurse best respond to the client? a. "Yes, this type of blindness could have been prevented by earlier treatment." b. "It is fortunate you came for treatment in time to save the sight of your other eye." c. "Nothing you could have done would have made any difference." d. "Surgery can still save the sight in your eye with removal of the cataract."

ANS: D Although sight is increasingly impaired as a cataract matures, no other damage is done to the eye by waiting. Removal of the cataract will result in improved vision, regardless of how long the cataract has been present. No indication suggests that the client will develop a cataract in the other eye. The other statements are inaccurate.

Which assessment alerts the nurse to the possible presence of a cataract in a client? a. Loss of central vision b. Loss of peripheral vision c. Dull aching in the eye and brow areas d. Blurred vision and reduced color perception

ANS: D As the lens becomes opaque and less able to refract light appropriately, the client experiences blurred vision and a reduced ability to distinguish among different colors. The development of a cataract does not typically cause loss of peripheral or central vision, nor does it result in aching in the brow area.

A client has conjunctivitis in both eyes and is being treated with topical antibiotics. Which statement by the client indicates a need for further teaching? a. "I'll avoid sharing washcloths or towels with other family members." b. "I will wash my hands after applying the eye ointment to each eye." c. "I will call the ophthalmologist if the drainage continues after the antibiotics are started." d. "I'll use the same tube of topical ointment for each infected eye."

ANS: D Bacterial conjunctivitis is highly contagious; therefore the client must avoid sharing anything with others that has the potential to come in contact with the infected eye, such as washcloths or towels. The client needs to protect from reinfection by washing hands frequently during application of the antibiotic ointment and must let the eye doctor know if drainage continues after treatment is begun. Separate tubes of eye ointment should be used, with one specifically labeled for each eye.

Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy? a. Blood in urine b. Left flank bruising c. Left flank discomfort d. Decreased urine output

ANS: D Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

Which finding by the nurse will be most helpful in determining whether a 67-year-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a. Bladder distention b. Foul-smelling urine c. Suprapubic discomfort d. Costovertebral tenderness

ANS: D Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI. DIF: Cognitive Level: Apply (application) REF: 1070 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because he is afraid it might affect his ability to have intercourse. Which action should the nurse take? a. Offer reassurance that sperm production is not affected by TURP. b. Discuss alternative methods of sexual expression besides intercourse. c. Provide education about the use of medications for erectile dysfunction (ED) occurring after TURP. d. Teach that ED is NOT a common complication following a TURP.

ANS: D ED is not a concern with TURP, although retrograde ejaculation is likely and the nurse should discuss this with the patient. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns.

The nurse is teaching a client about home care after cataract surgery. Which statement indicates that the client requires further teaching? a. "I am glad that I don't need an eye patch after the surgery." b. "I will try a cool compress to decrease the swelling around the operated eye." c. "Dark sunglasses will be necessary when I am in the sun." d. "Pain, nausea, and vomiting are normal after this surgery."

ANS: D Eye pain accompanied by nausea and vomiting is an indication of increased intraocular pressure and/or hemorrhage. This is an emergent situation and the surgeon must be contacted by the client. The other responses are correct. The client will not need an eye patch, cool compresses will decrease the slight swelling, and dark glasses are necessary outdoors until the pupil responds to sunlight.

The nurse will anticipate that a 61-yr-old patient who has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level will need teaching about a. cystourethroscopy. b. uroflowmetry studies. c. magnetic resonance imaging (MRI). d. transrectal ultrasonography (TRUS).

ANS: D In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to visualize the prostate for biopsy. Uroflowmetry studies help determine the extent of urine blockage and treatment, but there is no indication that this is a problem for this patient. Cystoscopy may be used before prostatectomy but will not be done until after the TRUS and biopsy. MRI is used to determine whether prostatic cancer has metastasized but would not be ordered at this stage of the diagnostic process. DIF: Cognitive Level: Apply (application) REF: 1270 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When working in the urology/nephrology clinic, which patient could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Patient who is scheduled for a renal biopsy after a recent kidney transplant b. Patient who will need monitoring for several hours after a renal arteriogram c. Patient who requires teaching about possible post-cystoscopy complications d. Patient who will have catheterization to check for residual urine after voiding

ANS: D LPN/LVN education includes common procedures such as catheterization of stable patients. The other patients require more complex assessments and/or patient teaching that are included in registered nurse (RN) education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 15-16 OBJ: Special Questions: Delegation; Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

A patient complains of leg cramps during hemodialysis. The nurse should first a. massage the patient's legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline.

ANS: D Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

26. Which information will the nurse include when teaching a patient with keratitis caused by herpes simplex type 1? a. Correct use of the antifungal eyedrops natamycin (Natacyn) b. How to apply corticosteroid ophthalmic ointment to the eyes c. Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs) d. Importance of taking all of the ordered oral acyclovir (Zovirax)

ANS: D Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Herpes simplex I is viral, not parasitic, or fungal. Natamycin may be used for Acanthamoeba keratitis caused by a parasite. NSAIDs can be used to treat the pain associated with keratitis

Which information will the nurse include when teaching a patient with keratitis caused by herpes simplex type 1? a. Correct use of the antifungal eyedrops natamycin (Natacyn) b. How to apply corticosteroid ophthalmic ointment to the eyes c. Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs) d. Importance of taking all of the ordered oral acyclovir (Zovirax)

ANS: D Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Herpes simplex I is viral, not parasitic, or fungal. Natamycin may be used for Acanthamoeba keratitis caused by a parasite. NSAIDs can be used to treat the pain associated with keratitis

The nurse is performing a psychosocial assessment of a young man diagnosed with testicular cancer. Which does the nurse include as a priority in the assessment? a. Encouraging the client to verbalize his thoughts and feelings to his health care provider b. Assisting the client in locating a support group for men with testicular cancer c. Asking the client to rate his fears of sexual deficiency on a scale of 1 to 10 d. Identifying all components of his support system, including his partner

ANS: D Part of conducting a psychosocial assessment is determining who makes up the client's support system. It would be ineffective merely to refer the client to a support group, ask him to rate his fears of sexual inadequacy, or encourage him to discuss thoughts and feelings not with the nurse, but with his provider.

A patient who has been diagnosed with stage 2 prostate cancer chooses the option of active surveillance. The nurse will plan to a. vaccinate the patient with sipuleucel-T (Provenge). b. provide the patient with information about cryotherapy. c. teach the patient about placement of intraurethral stents. d. schedule the patient for annual prostate-specific antigen testing.

ANS: D Patients who opt for active surveillance need to have annual digital rectal examinations and prostate-specific antigen testing. Vaccination with sipuleucel-T, cryotherapy, and stent placement are options for patients who choose to have active treatment for prostate cancer. DIF: Cognitive Level: Understand (comprehension) REF: 1269 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

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

After a transurethral resection of the prostate (TURP), a 64-yr-old patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes clots in the urine. Which action should the nurse take first? a. Increase the flow rate of the bladder irrigation. b. Administer the prescribed IV morphine sulfate. c. Give the patient the prescribed belladonna and opium suppository. d. Manually instill and then withdraw 50 mL of saline into the catheter.

ANS: D The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurse's first action should be to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain may be reduced. Increasing the flow rate of the irrigation will further distend the bladder and may increase spasms. The belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot. DIF: Cognitive Level: Analysis (analyze) REF: 1272 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A client is scheduled for a prostatectomy for benign prostatic hyperplasia (BPH). On the morning of surgery, the laboratory report on the client's urine indicates the presence of red blood cells, white blood cells, and bacteria. Which is the nurse's highest priority action? a. Document the report in the client's chart. b. Insert a new Foley catheter before surgery. c. Strain the client's urine. d. Assess the client's vital signs and notify the health care provider.

ANS: D The client may have a urinary tract infection. The nurse should obtain a set of vital signs and notify the provider of the laboratory results. Any surgery may need to be delayed if the client has infection. Documentation is needed after other actions have been taken. Inserting a catheter and straining the client's urine will not be beneficial.

When assessing a patient's consensual pupil response, the nurse should a. have the patient cover one eye while facing the nurse. b. observe for a light reflection in the center of both corneas. c. instruct the patient to follow a moving object using only the eyes. d. shine a light into one pupil and observe the response of both pupils.

ANS: D The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye, then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements.

When obtaining a health history from a 49-year-old patient, which patient statement is most important to communicate to the primary health care provider? a. "My eyes are dry now." b. "It is hard for me to see at night." c. "My vision is blurry when I read." d. "I can't see as far over to the side."

ANS: D The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging.

Which assessment information collected by the nurse may present a contraindication to a testosterone replacement therapy (TRT)? a. The patient has noticed a decrease in energy level for a few years. b. The patient's symptoms have increased steadily over the past few years. c. The patient has been using sildenafil (Viagra) several times every week. d. The patient has had a gradual decrease in the force of his urinary stream.

ANS: D The decrease in urinary stream may indicate benign prostatic hyperplasia (BPH) or prostate cancer, which are contraindications to the use of testosterone replacement therapy (TRT). The other patient data indicate that TRT may be a helpful therapy for the patient. DIF: Cognitive Level: Apply (application) REF: 1269 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 75-year-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? a. Discuss the increased risk for falls that is associated with impaired vision. b. Explain that there are many ways to compensate for decreases in visual acuity. c. Suggest ways of improving the patient's safety, such as using brighter lighting. d. Ask the patient more about what type of vision problems are being experienced.

ANS: D The nurse's initial action should be further assessment of the patient's concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment

A 75-year-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? a. Discuss the increased risk for falls that is associated with impaired vision. b. Explain that there are many ways to compensate for decreases in visual acuity. c. Suggest ways of improving the patient's safety, such as using brighter lighting. d. Ask the patient more about what type of vision problems are being experienced.

ANS: D The nurse's initial action should be further assessment of the patient's concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment.

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L d. Patient who has just returned from having hemodialysis and has a heart rate of 124/min

ANS: D The patient who is tachycardic after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications. The other patients also need assessments or interventions but are not at risk for life-threatening complications.

Which statement by a patient who had a cystoscopy the previous day should be reported immediately to the health care provider? a. "My urine looks pink." b. "My IV site is bruised." c. "My sleep was restless." d. "My temperature is 101."

ANS: D The patient's elevated temperature may indicate a bladder infection, a possible complication of cystoscopy. The health care provider should be notified so that antibiotic therapy can be started. Pink-tinged urine is expected after a cystoscopy. The insomnia and bruising should be discussed further with the patient but do not indicate a need to notify the health care provider. DIF: Cognitive Level: Apply (application) REF: 1060 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

In reviewing a 55-year-old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess a. visual acuity. b. pupil reaction. c. color perception. d. peripheral vision.

ANS: D The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma

In reviewing a 55-year-old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess a. visual acuity. b. pupil reaction. c. color perception. d. peripheral vision.

ANS: D The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma

Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? a. The patient complains of a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of "a curtain" over part of the visual field.

ANS: D The patient's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient's history of being hit in the eye

A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will need to use bright lights to read for at least the next week." b. "I will use drops to keep my pupils dilated until my appointment." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will cover up with long-sleeved shirts and pants for the next 5 days."

ANS: D The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment

Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)? a. Bladder irrigation decreases the risk of postoperative bleeding. b. Hydration and urine output are maintained by bladder irrigation. c. Antibiotics are infused continuously through the bladder irrigation. d. Bladder irrigation prevents obstruction of the catheter after surgery.

ANS: D The purpose of bladder irrigation is to remove clots from the bladder and prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or improve hydration. Antibiotics are given by the IV route, not through the bladder irrigation. DIF: Cognitive Level: Understand (comprehension) REF: 1274 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200? a. How to access audio books b. How to use a white cane safely c. Where Braille instruction is available d. Where to obtain specialized magnifiers

ANS: D Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living (ADLs). Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision

Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200? a. How to access audio books b. How to use a white cane safely c. Where Braille instruction is available d. Where to obtain specialized magnifiers

ANS: D Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living (ADLs). Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision.

When assisting a blind patient in ambulating to the bathroom, the nurse should a. take the patient by the arm and lead the patient slowly to the bathroom. b. have the patient place a hand on the nurse's shoulder and guide the patient. c. stay beside the patient and describe any obstacles on the path to the bathroom. d. walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.

ANS: D When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient.

ANS: B Bladder spasms and lack of urine output indicate that the nurse needs to assess the continuous bladder irrigation for kinks and may need to manually irrigate the patient's catheter. The other information will also require actions, such as having the patient take deep breaths and cough and discussing the need for antihypertensive medication prescriptions with the health care provider, but the nurse's first action should be to address the problem with the urinary drainage system. DIF: Cognitive Level: Apply (application) REF: 1274 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

After reviewing the electronic medical record shown in the accompanying figure for a patient who had transurethral resection of the prostate the previous day, which information requires the most rapid action by the nurse? a. Elevated temperature and pulse b. Bladder spasms and urine output c. Respiratory rate and lung crackles d. No prescription for antihypertensive drugs

A frail 72-year-old woman with stage 3 chronic kidney disease is cared for at home by her family. The patient has a history of taking many over-the-counter medications. Which over-the-counter medications should the nurse teach the patient to avoid? A.Aspirin B. Acetaminophen (Tylenol) C. Diphenhydramine (Benadryl) D.Aluminum hydroxide (Amphogel)

Aluminum hydroxide (Amphogel) Antacids (that contain magnesium and aluminum) should be avoided because patients with kidney disease are unable to excrete these substances. Also, some antacids contain high levels of sodium that further increase blood pressure. Acetaminophen and aspirin (if taken for a short period of time) are usually safe for patients with kidney disease. Antihistamines may be used, but combination drugs that contain pseudoephedrine may increase blood pressure and should be avoided.

The nurse is teaching the female client how to perform self-catheterization. Which of the following instructions is incorrect? A) It is important to maintain ascetic technique when performing this process. B) The catheterization should be performed every 4-6 hours C) If you have the urge to void in the middle of the night, try to pea. If that doesn't work, you may self-catheterize. D) Always dispose of the catheter after use

Answer: A. Patients who self-catheterize are instructed to use clean technique as aseptic technique is not feasible or as needed in the home setting. Catheterization should be performed at regular intervals. It can be performed in the middle of the night as necessary. The catheter should be disposed of after use, never reused.

The patients passed his kidney stone! During stone analysis, it is determined that the stone is composed of uric acid. Which of the following dietary restrictions would be recommended for this patient? A) Avoiding all shellfish B) Limiting calcium intake C) Restricting protein intake D) Drinking less than 1000 ml of water

Answer: A. Stones that are composed of uric acid can be prevented by consuming a low-purine diet (similar for gout). Foods high in purine include shellfish, organ meat, asparagus, and mushrooms. Limiting calcium or protein intake may be appropriate for the stone composed of calcium. Patients with previous kidney stones should be encouraged to drink plenty of fluids, more than 2 L a day

The client with urge incontinence asks you "How can I get rid of this process?" Which is the best response to this client? A) "It's important to accept that this is a natural part of aging" B) "You should avoid artificial sweeteners, caffeine, and alcohol" C) "It could help to void after every time you think of it" D) "Make sure you take your diuretic at bedtime. This will help you pea better"

Answer: B. these substances are bladder irritants and should be avoided. A voiding schedule is best for patient with incontinence, and patients may or not remember to void. Urinary incontinence is not a natural part of aging, and diuretics should not be taken after 4 p.m.

You are teaching a patient with urinary incontinence about the importance of increasing fluid intake. Which statement, if made by the patient, indicates correct understanding? A) "Increasing my fluid intake will help flush toxins out of my kidneys which helps prevent incontinence" B) "I should double my fluid intake over the next several days" C) "Increased fluids can help with my urinary incontinence by preventing constipation" D) "Like you said, if I drink more water my pea will no longer be bothersome to my bladder"

Answer: C. Increased fluids help by preventing constipation, reduce urge by lowering concentration of urine, and help prevent infection. Although drinking fluids can help promote excretion of toxins out of the body, this does not affect incontinence. Doubling fluid intake may be effective, but we are not aware of the patient's previous intake. Patients should be encouraged do drink 2000-3000 mL if they have no other fluid restrictions.

Ms. White, the nursing instructor, is teaching her students how to prevent infection in patients with an indwelling catheter. Which student demonstrates correct understanding? A) "Hanging the urine bag above the bladder will help prevent infection" B) "It's important to avoid using soap to clean the perineum in the patient with a catheter" C) "The urine bag should be emptied at least every 8 hours" D) "The tubing to the urinary catheter should never be unhooked unless a specimen needs to be taken"

Answer: C. The bag should be emptied at least every eight hours (more if there are large amounts of urine) to prevent the risk of bacterial proliferation. The bag should NEVER be hung above the level of the bladder or set on the ground. Soap and water can be used to clean the perineal area and around the catheter, and should be done twice a day. The tubing of the catheter should NEVER be disconnected, even for a specimen.

You are helping the patient who has just had a foley catheter removed to retrain their bladder. As the nurse you would do all of the following except: A) Encourage the patient to drink measured amounts of fluids B) Palpate the bladder to assess for distention C) Teach the client to report any sweating, cold hands, or feelings of anxiety D) Straight cath the patient if the residual urine is more than 50 mL

Answer: D. A straight catheter should only be used if the residual urine is more than 100 mL (urinary retention). Immediately after the voiding attmpt the bladder should be scanned to assess for urinary retention. All other strategies can be used.

The patient who has just undergone knee surgery has been found to have not peed in six hours. The nurse can do all of the following to encourage the patient to void except? A) Apply a warm compress to perineum B) Offering hot fluids C) Run water in background D) Helping the patient onto the bedpan

Answer: D. The bedpan is evil for people with urinary retention. It is much more comfortable to pee in a sitting or standing position. Warmth in the form of compresses and hot beverages can help stimulate urination. Running water from a faucet may also trigger the patient to pee. IF the patient cannot void, the bladder should be scanned and catheterization may be necessary.

The client you are taking care of has just been diagnosed with nephrolithiasis. Upon assessment, which priority question should the nurse ask the client? A) Have you seen any blood in your urine? B) Are you have any pain? C) What is your typical diet? D) Have you had any burning pea?

Answer: D. This question assesses for the possibility of developing an infection, a complication of nephrolithiasis (kidney stones). Pain and hematuria would be expected in this patient. Diet can be helpful in preventing kidney stone formation, but it is not a priority question.

A 78-year-old patient has Stage 3 CKD and is being taught about a low potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? A.Apple, green beans, and a roast beef sandwich B.Granola made with dried fruits, nuts, and seeds C.Watermelon and ice cream with chocolate sauce D.Bran cereal with ½ banana and milk and orange juice

Apple, green beans, and a roast beef sandwich Correct When the patient selects an apple, green beans, and a roast beef sandwich, the patient demonstrates understanding of the low potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have elevated levels of potassium, at or above 200 mg per 1/2 cup.

A 52-year-old man with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which action should the nurse take? A.Assess skin turgor to determine hydration status. B.Insert a urinary catheter for the expected diuresis. C.Evaluate the patient's lower extremities for edema D. Check the patient's urine for the presence of ketones

Assess skin turgor to determine hydration status. Preexisting kidney disease is the most important risk factor for the development of contrast-associated nephropathy and nephrotoxic injury. If contrast media must be administered to a high-risk patient, the patient needs to have optimal hydration. The nurse should assess the hydration status of the patient before the procedure is performed. Indwelling catheter use should be avoided whenever possible to decrease the risk of infection.

Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

B Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate

A nurse is caring for a client receiving hemodialysis who has an internal arteriovenous (AV) fistula. Which assessment finding would indicate to the nurse that the fistula is patent? a) white fibrin specks noted in the fistula b) palpation of a thrill over the site of the fistula c) lack of bruit over the site of the fistula d) a feeling of warmth at the site of the fistula

B - An internal AV fistula is created through a surgical procedure in which an artery in the arm is anastomosed to a vein. To assess patency, the nurse palpates over the fistula for a thrill and auscultates for a bruit. With an internal AV fistula, the nurse would not note white fibrin specks. A feeling of warmth at the site of the fistula may indicate an inflammatory process.

A nurse has collected nutritional data from a client with a diagnosis of cystitis. The nurse determines that which beverage needs to be eliminated from the client's diet to minimize the recurrence of cystitis? a) fruit juice b) tea c) water d) lemonade

B - Caffeine and alcohol can irritate the bladder. Therefore, alcohol and caffeine-containing beverages such as coffee, tea, and cocoa are avoided to minimize the risk. Water helps flush bacteria out of the bladder, and an intake of six to eight glasses per day is encouraged. Lemonade and fruit juice are acceptable items to drink.

A nurse is giving a client with polycystic kidney disease instructions in replacing elements lost in the urine as a result of impaired kidney function. The nurse instructs the client to increase intake of which of the following in the client? a) sodium and potassium b) sodium and water c) water and phosphorus d) calcium and phosphorus

B - Clients with polycystic kidney disease waste sodium rather than retain it and therefore need an increase in sodium and water in the diet. Potassium, calcium, and phosphorus do not need to be increased in this condition.

A nurse is caring for a client newly diagnosed with chronic renal failure who has recently begun hemodialysis. The nurse determines that the client has not tolerated the procedure optimally if the client experiences which symptoms that represent disequilibrium syndrome? a) restlessness, irritability, and generalized weakness b) headache, deteriorating level of consciousness, and seizures c) hypertension, tachycardia, and fever d) hypotension, bradycardia, and hypothermia

B - Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from the rapid removal of solutes from the body during hemodialysis. The blood-brain barrier interferes with equally efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It most often occurs in clients who are new to dialysis, and is prevented by dialyzing for shorter times or at reduced blood flow rates.

A client with chronic renal failure has completed a hemodialysis treatment. The nurse measures which parameters at the completion of the hemodialysis procedure to monitor for hemodynamic stability and to determine effectiveness of fluid extraction? a) vital signs and blood urea nitrogen (BUN) b) vital signs and weight c) sodium and potassium levels d) BUN and creatinine levels

B - Following dialysis, the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client's "dry weight" to determine effectiveness of fluid extraction. Laboratory studies are done as per protocol, but are not necessarily done after the hemodialysis treatment has been ended.

A nurse is working with a client newly diagnosed with chronic renal failure to set up schedule for hemodialysis. The client states, "This is so unfair I wouldn't have to do this for the rest of my life if you people had caught this disease in time!" The nurse interprets that the client is exhibiting: a) anger b) projection c) withdrawal d) depression

B - Psychosocial reactions to chronic renal failure and hemodialysis are varied and may include personality changes, emotional lability, withdrawal, depression, and anger. The individual client response may vary depending on the client's personality and support systems. The client in this question is exhibiting projection. The client is blaming the nurse and other health care personnel for the client's situation.

A nurse has provided instructions to a client with a nephrotostomy tube regarding home care after hospital discharge. The nurse determines that the client understands the instructions if the client verbalizes to drink approximately how many 8-ounce glasses of water per day? a) 2 b) 8 c) 16 d) 20

B - The client with a nephrostomy tube needs to have adequate fluid intake to dilute urinary particles that could cause calculus and to provide mechanical flushing of the kidney and tube. The nurse encourages the client to take in 2000 mL of fluid per day, which is roughly equivalent to eight 8-ounce glasses of water. Option A identifies a fluid intake volume that is too low and would not provide mechanical flushing of the kidney and tube. Options C and D identify very large volumes of fluid intake; these volumes are unnecessary and could possibly place undo distention on the renal pelvis.

A client undergoing hemodialysis becomes hypotensive. The nurse immediately prepares to take which action? a) administer 1000 ml 5% dextrose in water b) administer a 250 ml normal saline bolus c) increase the blood flow into the dialyzer d) lower the client's legs and feet

B - To treat hypotension during hemodialysis, a normal saline bolus of up to 500 mL may be given. The client's feet and legs are raised to enhance cardiac return. Albumin may be given as per protocol to increase colloid oncotic pressure. The blood flow rate into the dialyzer may be decreased. All of these measures should improve the circulating volume and blood pressure. Five percent dextrose in water is not prescribed because it is less likely to improve the circulating volume and blood pressure.

A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN? a. Evaluate the IV insertion site for extravasation. b. Monitor the patient's BP and heart rate every hour. c. Adjust the rate to keep the systolic BP >90 mm Hg. d. Teach the patient the reasons for remaining on bed rest.

B An experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, making adjustments to the drip rate for vasoactive medications, and monitoring for serious complications such as extravasation require RN level education and scope of practice.

A 55-year-old with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is appropriate? a. "Since you are diabetic, you would not be a candidate for a heart transplant." b. "The choice of a patient for a heart transplant depends on many different factors." c. "Your heart failure has not reached the stage in which heart transplants are considered." d. "People who have heart transplants are at risk for multiple complications after surgery."

B Indications for a heart transplant include end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patient's question.

A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to a. give IV diazepam (Valium) 2.5 mg. b. administer IV morphine sulfate 2 mg. c. increase nitroglycerin (Tridil) infusion by 5 mcg/min. d. increase dopamine (Intropin) infusion by 2 mcg/kg/min.

B Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it also will increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

14. The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in ADHF. When assessing the patient, the nurse will be most concerned about a. an apical pulse rate of 106 beats/min. b. an oxygen saturation of 88% on room air. c. weight gain of 1 kg (2.2 lb) over 24 hours. d. decreased hourly patient urinary output.

B Rationale: A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action. Cognitive Level: Analysis Text Reference: pp. 829-830 Nursing Process: Assessment NCLEX: Physiological Integrity

22. A patient who is receiving dobutamine (Dobutrex) for the treatment of ADHF has all of the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN? a. Teach the patient the reasons for remaining on bed rest. b. Monitor the patient's BP every hour. c. Adjust the drip rate to keep the systolic BP >90 mm Hg. d. Call the health care provider about a decrease in urine output.

B Rationale: An experienced LPN/LVN would be able to monitor BP and would know to report significant changes to the RN. Teaching patients and making adjustments to the drip rate for vasoactive medications are RN-level skills. Because the health care provider may order changes in therapy based on the decrease in urine output, the RN should call the health care provider about the decreased urine output. Cognitive Level: Application Text Reference: pp. 827-829 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

5. When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage 1 hypertension, the information that is most likely to improve compliance with antihypertensive therapy is that a. hypertensive crisis may lead to development of acute heart failure in some patients. b. hypertension eventually will lead to heart failure by overworking the heart muscle. c. high BP increases risk for rheumatic heart disease. d. high systemic pressure precipitates papillary muscle rupture.

B Rationale: Hypertension is a primary cause of heart failure because the increase in ventricular afterload leads to ventricular hypertrophy and dilation. Hypertensive crisis may precipitate acute heart failure is some patients, but this patient with stage 1 hypertension may not be concerned about a crisis that happens only to some patients. Hypertension does not directly cause rheumatic heart disease (which is precipitated by infection with group A -hemolytic streptococcus) or papillary muscle rupture (which is caused by myocardial infarction/necrosis of the papillary muscle). Cognitive Level: Application Text Reference: p. 822 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

8. A patient admitted to the hospital with an exacerbation of chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse can best document this assessment information as a. pulsus alternans. b. paroxysmal nocturnal dyspnea. c. two-pillow orthopnea. d. acute bilateral pleural effusion.

B Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period. Cognitive Level: Comprehension Text Reference: p. 825 Nursing Process: Assessment NCLEX: Physiological Integrity

7. Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops a. a drop in heart rate to 54 beats/min. b. a systolic BP <90 mm Hg. c. any symptoms indicating cyanide toxicity. d. an increased amount of ventricular ectopy.

B Rationale: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. After 48 hours of continuous use, cyanide toxicity is a possible (though rare) adverse effect. Reflex tachycardia (not bradycardia) is another adverse effect of this medication. Nitroprusside does not cause increased ventricular ectopy. Cognitive Level: Application Text Reference: p. 828 Nursing Process: Evaluation NCLEX: Physiological Integrity

10. The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient a. says that the nitroglycerin patch will be used for any chest pain that develops. b. calls when the weight increases from 124 to 130 pounds in a week. c. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime. d. makes an appointment to see the doctor at least once yearly.

B Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as necessary" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. Heart failure is a chronic condition that will require frequent follow-up rather than an annual health care provider examination. Cognitive Level: Application Text Reference: pp. 826, 833-834, 838 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

15. While admitting an 80-year-old patient with heart failure to the medical unit, the nurse obtains the information that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." The nurse makes a note that discharge planning for the patient will need to include a. transfer to a dementia care service. b. referral to a home health care agency. c. placement in a long-term-care facility. d. arrangements for around-the-clock care.

B Rationale: The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient to develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as dementia care, long-term-care, or around-the-clock home care. Cognitive Level: Application Text Reference: pp. 836-837 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

A nurse is developing a plan of care for a client with nephrotic syndrome. The nurse documents that which important parameter needs to be assessed on a daily basis? a) total protein levels b) weight c) blood urea nitrogen (BUN) d) activity tolerance

B The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels are monitored as they are ordered, as are the BUN and creatinine levels. The client's activity level is adjusted according to the amount of edema and water retention. As edema increases, the client's activity level should be restricted.

While admitting an 80-year-old with heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a. transfer to a dementia care service. b. referral to a home health care agency. c. placement in a long-term care facility. d. arrangements for around-the-clock care.

B The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as dementia care, long-term care, or around-the-clock home care.

After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will take a laxative every night before going to bed. b. I must increase my intake of dietary fiber and fluids. c. I shall only use salt when I am cooking my own food. d. I'll eat white bread to minimize gastrointestinal gas.

B ~ Clients with PKD often have constipation, which can be managed with increased fiber, exercise, and drinking plenty of water. Laxatives should be used cautiously. Clients with PKD should be on a restricted salt diet, which includes not cooking with salt. White bread has a low fiber count and would not be included in a high-fiber diet.

A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider? a. Flank pain b. Periorbital edema c. Bloody and cloudy urine d. Enlarged abdomen

B ~ Periorbital edema would not be a finding related to PKD and should be investigated further. Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection.

After teaching a client with hypertension secondary to renal disease, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. I can prevent more damage to my kidneys by managing my blood pressure. b. If I have increased urination at night, I need to drink less fluid during the day. c. I need to see the registered dietitian to discuss limiting my protein intake. d. It is important that I take my antihypertensive medications as directed.

B ~ The client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions. These clients should be assessed thoroughly for potential dehydration. Increased nocturnal voiding can be decreased by consuming fluids earlier in the day. Blood pressure control is needed to slow the progression of renal dysfunction. When dietary protein is restricted, refer the client to the registered dietitian as needed.

You are working as the charge nurse in the emergency department when a 60-year-old who has had vomiting and diarrhea for the last 2 days arrives. Vital signs are: T: 101.8° F (38.8° C) HR: 112 RR: 24 BP: 88/60 Which action prescribed by the health care provider will you implement first? A. Give metoclopramide (Reglan) 10 mg IV. B. Infuse 1 L of normal saline over 60 minutes. C. Draw blood for complete blood count and blood chemistries. D. Administer acetaminophen (Tylenol) 650 mg rectal suppository

B ~ Volume depletion is the most common cause of acute kidney injury. This patient's history, BP, and pulse indicate severe hypovolemia; rapid isotonic fluid replacement is needed to improve perfusion to the kidneys and avoid acute prerenal kidney injury. The other actions are also appropriate, but replacement of volume loss and maintenance of perfusion to vital organs is the most immediate need for this patient

The nurse is caring for a client immediately following a transurethral prostatectomy (TURP). The nurse places high priority on which nursing interventions in the immediate post-op period for this client? Select all that apply. A) Asses for signs of a UTI B) Prevent post-op atelectasis C) Discontinue urinary catheter asap D) Adjust flow rate of the bladder irrigant to keep catheter patent E) Monitor the amount of blood in the urine

B, D, E

A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (SATA) a. Clear drainage b. Bloody drainage at site c. Client reports headache d. Foul-smelling drainage e. Urine draining from site

B, D, E ~ After a nephrostomy, the nurse should assess the client for complications and urgently notify the provider if drainage decreases or stops, drainage is cloudy or foul-smelling, the nephrostomy sites leaks blood or urine, or the client has back pain. Clear drainage is normal. A headache would be an unrelated finding.

A patient with hypertension and stage 2 chronic kidney disease (CKD) is receiving captopril (Capoten). Before administration of the medication, the nurse will check the patient's a. glucose b. potassium. c. creatinine d. phosphate

B. Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values also would be monitored in patients with CKD but would not affect whether the captopril was given or not.

You're caring for a patient with acute renal failure undergoing hemodialysis through an arteriovenous (AV) fistula in the right arm. Which of the following shouldn't be included in the care plans for this patient? A. Assess the AV fistula for a thrill and bruit B. Only draw blood from the access arm C. Apply gentle pressure to the site if breakthrough bleeding occurs between dialysis treatments D. Use two needles for the hemodialysis treatment

B. Only draw blood from the access arm

The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which clinical manifestations, if assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? A. Fatigue, orthopnea, and dependent edema B. Severe dyspnea and blood-streaked, frothy sputum C. Temperature is 100.4o F and pulse is 102 beats/minute D. Respirations 26 breaths/minute despite oxygen by nasal cannula

B. Severe dyspnea and blood-streaked, frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate > 30 breaths per minute, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? A. Withhold the daily dose until the following day. B. Withhold the dose and report the potassium level. C. Give the digoxin with a salty snack, such as crackers. D. Give the digoxin with extra fluids to dilute the sodium level.

B. Withhold the dose and report the potassium level. The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The physician may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.

A nurse is teaching a client about digitalis and dietary considerations. Which food should the nurse​ recommend? Bananas Green leafy vegetables Potato chips ​Low-fat milk

Bananas Rationale: When taking​ digitalis, low potassium levels​ (hypokalemia) increase the risk of digitalis toxicity. Bananas are high in​ potassium, while​ low-fat milk, green leafy​ vegetables, and potato chips are low in potassium. Clients should be given a list of​ high-potassium foods, scheduled to have their digitalis levels checked​ frequently, and instructed to call with any symptoms of digitalis toxicity.

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalance? A. hyperkalemia and hyponatremia B. hyperkalemia and hypernatremia C. hypokalemia and hyponatremia D. hypokalemia and hypernatremia

C

Measures indicated in the conservative therapy of chronic kidney disease include: A. decreased fluid intake, carbohydrate intake, and protein intake B. increased fluid intake, decreased carbohydrate intake and protein intake C. decreased fluid intake and protein intake, increased carbohydrate intake D. decreased fluid intake and carbohydrate intake, increased protein intake

C

To assess the patency of a newly places arteriovenous graft for dialysis, the nurse should: A. irrigate the graft daily with low-dose heparin B. monitor for any increase of BP in the affected arm C. listen with a stethoscope over the graft for presence of a bruit D. frequently monitor the pulses and neurovascular status distal to the graft

C

2. A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. The nurse's first action will be to a. ask the patient to recall the dietary intake for the last 3 days because there may be hidden sources of sodium in the patient's diet. b. instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by excessive intake of inappropriate foods. c. assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring. d. educate the patient about the use of diuretic therapy because it is likely that the patient will need medications to reduce the hypervolemia.

C Rationale: The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening; it is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet and teaching about diuretic therapy are appropriate interventions but are not the first nursing actions indicated. There is no evidence that the patient's weight gain is caused by excessive dietary intake of fat or calories, so the answer beginning "instruct the patient in a low-calorie, low-fat diet" describes an inappropriate action. Cognitive Level: Application Text Reference: p. 826 Nursing Process: Assessment NCLEX: Physiological Integrity

A client has undergone urinary diversion after cystectomy for bladder cancer. The nurse assesses the urostomy stoma to ensure that it is: a) pale and pink b) pink and dry c) red and moist d) dusky to beefy colored

C - Following urostomy, the stoma should be red and moist. It may be edematous, but this will decrease after the first few days. A dusky or cyanotic color indicates insufficient circulation with impending necrosis and warrants notification of the surgeon immediately.

A client is undergoing hemodialysis and receives heparin during the dialysis procedure. The nurse monitors the results of which of the following laboratory tests during the dialysis procedure? a) thrombin time b) bleeding time c) partial thromboplastin time (PTT) d) prothrombin time (PT)

C - Heparin is used as an anticoagulant during hemodialysis. The hemodialysis nurse monitors the extent of anticoagulation by measuring the PTT, which measures heparin effect. The PT is measured to monitor the effect of warfarin (Coumadin) therapy. Thrombin and bleeding times are not used to measure the effect of heparin therapy, although they are useful in the diagnosis of other clotting abnormalities.

A nurse is developing a teaching plan for a client with chronic renal failure who has been started on hemodialysis. The nurse would plan to include which of the following pieces of information in discussions with the client? a) it's unnecessary to stay within the fluid restriction on the day before hemodialysis b) it's all right to eat unlimited protein on the day before hemodialysis c) daily medications should be taken after hemodialysis, not before d) daily medications should be double-dosed if going for hemodialysis that day

C - Many medications are dialyzable, which means they are removed from the bloodstream during dialysis. Because of this, many medications are withheld on the day of dialysis until after the procedure. It is not typical for medications to be "double-dosed" because there is no way to be certain how much of each medication is cleared by dialysis. Clients receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions.

A nurse provides home care instructions to a client hospitalized for a transurethral resection of the prostate (TURP). Which statement by the client indicates a need for further instructions? a) I need to avoid strenuous activity for 4 to 6 weeks b) I need to maintain a daily intake of 6 to 8 glasses of water daily c) I need to avoid lifting items greater than 30 pounds d) I need to include prune juice in my diet

C - The client needs to be advised to avoid strenuous activity for 4 to 6 weeks and to avoid lifting items weighing greater than 20 pounds. The client needs to consume an intake of at least 6 to 8 glasses daily of nonalcoholic fluids to minimize clot formation. Straining during defecation for at least 6 weeks after surgery is avoided to prevent bleeding. Prune juice is a satisfactory bowel stimulant.

A client with pyelonephritis is being discharged from the hospital, and the nurse provides instructions to the client to prevent recurrence. The nurse determines that the cleint understands the information that was given if hte client states an intention to: a) increase fluids for 2 days if signs and symptoms of a urinary tract infection develop b) take the prescribed antibiotics until all symptoms subside c) return to the physician's office for scheduled follow-up urine cultures d) decrease fluid intake if frequent urination occurs

C - The client with pyelonephritis should take the full course of antibiotic therapy that has been prescribed and return to the physician's office for follow-up urine cultures if so instructed. The client should learn the signs and symptoms of a urinary tract infection, and report them immediately if they occur. The client should also drink 3 L of fluid per day.

A client with chronic renal failure is on a fluid restriction and receives aluminum hydroxide gel (ALternaGEL) as a phosphate binder. The nurse determines that the client is at risk for which problem (nursing diagnosis) because of these treatment measures? a) fatigue b) deficient fluid volume c) constipation d) ineffective coping

C - The client with renal failure is almost certain to have a problem with constipation due to factors such as fluid restriction and dietary restrictions of most high-fiber foods (which have high potassium content). In addition, aluminum-based antacids such as aluminum hydroxide gel cause constipation as a side effect. There is no information in the question to support any of the other options, although the client with renal failure is commonly fatigued.

A nurse is explaining the concept of fluid restriction to a client with chronic renal failure who has started hemodialysis. The nurse tells the client that the fluid restriction is planned by adding the amount of the daily urine output (if any) and: a) 1800 to 2000 ml b) 1200 to 1500 ml c) 500 to 700 ml d) 200 to 300 ml

C - The usual allowable daily fluid intake of the hemodialysis client is the total of the daily urine output plus 500 to 700 mL. Options 1 and 2 identify high volumes of fluid intake, and option 4 identifies an insufficient volume.

A patient has recently started taking oral digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for control of heart failure. Which assessment finding by the home health nurse is most important to communicate to the health care provider? a. Presence of 1 to 2+ edema in the feet and ankles b. Liver is palpable 2 cm below the ribs on the right side. c. Serum potassium level is 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

C Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which also can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. canned and frozen fruits. b. fresh or frozen vegetables. c. milk, yogurt, and other milk products. d. eggs and other high-cholesterol foods.

C Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000 mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include a. avoid dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider about any nausea. d. never take digoxin if the pulse is below 60 beats/minute.

C Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

20. An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is a. 12-lead electrocardiogram (ECG). b. arterial blood gases (ABGs). c. B-type natriuretic peptide (BNP). d. serum creatine kinase (CK).

C Rationale: BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP. Cognitive Level: Application Text Reference: p. 827 Nursing Process: Assessment NCLEX: Physiological Integrity

9. During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to venous congestion. b. disturbed body image related to massive leg swelling. c. impaired skin integrity related to peripheral edema. d. impaired gas exchange related to chronic heart failure.

C Rationale: The patient's findings of severe dependent edema and weeping serous fluid from the legs support the nursing diagnosis of impaired skin integrity. There is less evidence for the nursing diagnoses of activity intolerance, disturbed body image, and impaired gas exchange, although the nurse will further assess the patient to determine whether there are other clinical manifestations of heart failure to indicate that these diagnoses are appropriate. Cognitive Level: Application Text Reference: p. 836 Nursing Process: Diagnosis NCLEX: Physiological Integrity

The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient a. uses an additional pillow to sleep when feeling short of breath at night. b. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime. c. calls the clinic when the weight increases from 124 to 130 pounds in a week. d. says that the nitroglycerin patch will be used for any chest pain that develops.

C Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as necessary" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by elevating the head of the bed further.

A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, "What can I do to help prevent these infections?" How should the nurse respond? a. Test your urine daily for the presence of ketone bodies and proteins. b. Use tampons rather than sanitary napkins during your menstrual period. c. Drink more water and empty your bladder more frequently during the day. d. Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled.

C ~ Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the client's sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth. Testing urine and using tampons will not help prevent pyelonephritis. A hemoglobin A1c of 9% is too high.

The patient was admitted to the medical unit with a diagnosis of dehydration. 48 hours later you are reviewing the results of today's diagnostic testing. Which result is most important to report to the health care provider? A. Blood urea nitrogen (BUN) 76 mg/dL B. Hematocrit 33% C. Serum potassium 7.2 mEq/L D. Glomerular filtration rate (GFR) 25 mL/minut

C ~ The serum potassium level indicates severe hyperkalemia, which may result in bradycardia and cardiac arrest unless it is corrected quickly. The elevated BUN and decreased GFR indicate that the patient has developed acute kidney injury and will also need to be reported but are not immediately life threatening. The patient's anemia may be chronic, or caused by hemodilution or by decreased erythropoietin production by the injured kidneys, but does not need to be addressed immediately

A 54-year-old male patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? A. Perform a bladder scan to assess for urinary retention. B. Restrict the patient's oral fluid intake to 500 mL per day. C. Assist the patient to a sitting position with arms on the overbed table. D. Instruct the patient to use pursed-lip breathing until the dyspnea subsides.

C. Assist the patient to a sitting position with arms on the overbed table. The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.

Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider? a. the urine output is 900-1110 ml/hr b. the BUN and creatinine levels are elevated c. The patient's central venous pressure (CVP) is decreased. d. the patient has a level 8 incisional pain

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

Which information about a patient who was admitted 10 days previously with acute kidney injury (AKI) caused by dehydration will be most important for the nurse to report to the health care provider? a. BUN is 67 b. creatinine is 3.0 c. Urine output over an 8-hour period is 2500 mL. d. GFR is <30ml

C. The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

The patient has had type 1 diabetes mellitus for 25 years and is now reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse finds that the patient has newly developed hypertension and difficulty with blood glucose control. The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? A.Serum creatinine B.Serum potassium C.Microalbuminuria D.Calculated glomerular filtration rate (GFR)

Calculated glomerular filtration rate (GFR) The best study to determine kidney function or chronic kidney disease (CKD) that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient's age, gender, race, and serum creatinine. It would need to be abnormal for 3 months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD.

A client newly diagnosed with heart failure is prescribed​ digitalis, a positive inotropic drug. Which sign and symptom would the nurse instruct the client to report to the healthcare​ provider? (Select all that​ apply.) Confusion Weight loss Nausea Weight gain Vision changes

Confusion Weight loss Nausea Vision changes Rationale: Digitalis increases the strength of myocardial contraction by increasing intracellular calcium concentrations. It also increases ventricular filling time by decreasing SA node automaticity and slowing the conduction time through the AV node. Since digitalis has a narrow therapeutic​ index, therapeutic levels are very close to toxic levels. Signs of digitalis toxicity include poor​ appetite, anorexia, nausea and​ vomiting, headache, altered​ vision, and confusion. Clients should be instructed to contact their healthcare provider if they experience any of these symptoms. Older adults are at a greater risk for digitalis toxicity than younger clients.

The physician has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient? A.Hemodialysis (HD) 3 times per week B.Automated peritoneal dialysis (APD) C.Continuous venovenous hemofiltration (CVVH) D. Continuous ambulatory peritoneal dialysis (CAPD)

Continuous venovenous hemofiltration (CVVH) CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection. HD 3 times per week would not be used for this patient because fluid and solutes build up and then are rapidly removed. With APD (used at night instead of during the day) fluid and solutes build up during the day and would not benefit this patient as much. CAPD will not as rapidly remove large amounts of fluid as CVVH can do.

A 32-year-old man scheduled for a unilateral orchiectomy for testicular cancer is admitted to the hospital the morning of surgery. He is accompanied by his wife but does not talk to her and does not initiate interaction with the nurse. The most appropriate action by the nurse is to a. ask the patient if he has any questions or concerns about the diagnosis and treatment. b. tell the patient's wife that concerns about sexual function are common with this diagnosis. c. teach the patient that impotence is rarely a problem after unilateral orchiectomy. d. document the patient's lack of communication on the chart and continue preoperative care.

Correct Answer: A Rationale: The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, it is inappropriate for the nurse to initiate teaching. It would be inappropriate for the nurse to provide patient teaching without further assessment of the patient's teaching needs and concerns. Documentation of the patient's lack of interaction is not an adequate nursing action in this situation.

The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate? a. "The bladder irrigation is needed to stop the postoperative bleeding in the bladder." b. "The irrigation is needed to keep the catheter from being occluded by blood clots." c. "Normal production of urine is maintained with the irrigations until healing occurs." d. "Antibiotics are being administered into the bladder with the irrigation solution."

Correct Answer: B Rationale: The purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or maintain urine production. Antibiotics are given by the IV route, not through the bladder irrigation.

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. the presence of blood in the urine. b. any erectile dysfunction (ED). c. occurrence of a weak urinary stream. d. lower back and hip pain.

Correct Answer: C Rationale: The American Urological Association (AUA) Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and back or hip pain are not typical symptoms with BPH.

The health care provider orders a blood test for prostate-specific antigen (PSA) when an enlarged prostate is palpated during a routine examination of a 56-year-old man. When the patient asks the nurse the purpose of the test, the nurse's response is based on the knowledge that a. elevated levels of PSA are indicative of metastatic cancer of the prostate. b. PSA testing is the "gold standard" for making a diagnosis of prostate cancer. c. baseline PSA levels are necessary to determine whether treatment is effective. d. PSA levels are usually elevated in patients with cancer of the prostate.

Correct Answer: D Rationale: PSA levels are usually elevated above the normal in patients with prostate cancer. PSA testing does not determine whether metastasis has occurred. A biopsy of the prostate is needed for a definitive diagnosis of prostate cancer. Success of treatment is determined by a fall in PSA to an undetectable level; the patient's baseline PSA is not needed to determine the success of treatment.

Which information will be most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)? a. Blood urea nitrogen (BUN) level b. Urine output c. Creatinine level d. Calculated glomerular filtration rate (GFR)

D GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

A client with chronic renal failure has been on dialysis for 4 years and has been taking aluminum hydroxide (Amphojel tablets) as prescribed as part of the medication regimen. The client develops confusion and dementia, and complains of bone pain. The nurse interprets that this client is at risk for developing: a) advancing uremia b) folic acid defieciency c) phosphate overdose d) aluminum intoxication

D - Aluminum intoxication can occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. Symptoms include mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This complication is treated with aluminum chelating agents, which make aluminum available to be dialyzed from the body. It is prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.

A client with chronic renal failure has undergone insertion of an indwelling catheter in the abdomen for peritoneal dialysis. The nurse teaches the client to do which of the following if the peritoneal catheter dressing gets wet? a) flush the peritoneal dialysis catheter b) scrub the catheter with povidone-iodine c) reinforce the dressing d) change the dressing

D - Clients with peritoneal dialysis catheters are at high risk for infection. A dressing that is wet is a conduit for bacteria to reach the catheter insertion site. The nurse teaches the client to keep the dressing dry at all times. Reinforcing the dressing is not a safe practice to prevent infection. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.

a nurse has formulated a nursing diagnosis of Risk for Infection for a hemodialysis client with an arteriovenous (AV) fistula in the right arm. The nurse determines that the client has best met the outcome criteria for this nursing diagnosis if which of the following observations is made? a) the client states her or she should do careful handwashing once a day b) the client states her or she should avoid blood pressure measurement in the right arm c) the client's temperature does not exceed 100.6F d) the client's white blood cell (WBC) count is 7500/mm3

D - General indicators that the client is not experiencing infection include a normal temperature and a normal WBC count. Option C is incorrect because the temperature is elevated above normal. The client should also use proper handwashing technique as a general preventive measure; however, handwashing once per day is insufficient, and is therefore incorrect. It is true that the client should avoid blood pressure measurement in the affected arm; however, this would relate more closely to the nursing diagnosis Risk for injury.

A nurse is giving suggestions to a client with chronic renal failure about ways to reduce pruritus from uremia. The nurse tells the client to avoid which type of skin care product? a) lanolin-based lotion b) bath oil c) mild soap d) astringent cleansing pads

D - The client with chronic renal failure often has dry skin, accompanied by itching (pruritus) from uremia. The client should use mild soaps, lotions, and bath water oils to reduce dryness without increasing skin irritation. Products that contain perfumes or alcohol increase dryness and pruritus, and should be avoided.

The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is a. weight loss of 2 pounds overnight. b. hourly urine output greater than 60 mL. c. reduction in patient complaints of chest pain. d. decreased dyspnea with the head of bed at 30 degrees.

D Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient's response.

A patient who has chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment information as a. pulsus alternans. b. two-pillow orthopnea. c. acute bilateral pleural effusion. d. paroxysmal nocturnal dyspnea.

D Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.

17. Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations, such as digoxin (Lanoxin). b. calcium-channel blockers, such as diltiazem (Cardizem). c. -adrenergic agonists, such as dobutamine (Dobutrex). d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

D Rationale: ACE-inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium-channel blockers are not generally used in the treatment of heart failure. The -adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Implementation NCLEX: Physiological Integrity

4. The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is a. weight loss of 2 pounds overnight. b. improvement in hourly urinary output. c. reduction in systolic BP. d. decreased dyspnea with the head of the bed at 30 degrees.

D Rationale: Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in crackles. The other assessment data also may indicate that diuresis or improvement in cardiac output have occurred but are not as useful in evaluating this patient's response. Cognitive Level: Application Text Reference: p. 825 Nursing Process: Evaluation NCLEX: Physiological Integrity

23. A hospitalized patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about captopril, which statement by the patient indicates that teaching has been effective? a. "I will need to include more high-potassium foods in my diet." b. "I will expect to feel more short of breath for the next few days." c. "I will be sure to take the medication after eating something." d. "I will call for help when I need to get up to the bathroom."

D Rationale: Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE inhibitors are potassium sparring, and the nurse should not teach the patient to increase sources of dietary potassium. Increased shortness of breath is expected with initiation of -blocker therapy for heart failure, not for ACE-inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Evaluation NCLEX: Physiological Integrity

13. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin), hydrochlorothiazide (HydroDIURIL), and a potassium supplement. Appropriate instructions for the patient include a. avoid dietary sources of potassium because too much can cause digitalis toxicity. b. take the pulse rate daily and never take digoxin if the pulse is below 60 beats/min. c. take the hydrochlorothiazide before bedtime to maximize activity level during the day. d. notify the health care provider immediately if nausea or difficulty breathing occurs.

D Rationale: Difficulty breathing is an indication of acute decompensated heart failure and suggests that the medications are not achieving the desired effect. Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. Digoxin toxicity is potentiated by hypokalemia, rather than hyperkalemia. Patients should be taught to check their pulse daily before taking the digoxin and, if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption. Cognitive Level: Application Text Reference: p. 835 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

18. A 55-year-old patient with inoperable coronary artery disease and end-stage heart failure asks the nurse whether heart transplant is a possible therapy. The nurse's response to the patient will be based on the knowledge that a. heart transplants are experimental surgeries that are not covered by most insurance. b. the patient is too old to be placed on the transplant list. c. the diagnoses and symptoms indicate that the patient is not an appropriate candidate. d. candidacy for heart transplant depends on many factors.

D Rationale: Indications for a heart transplant include inoperable coronary artery disease and refractory end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous post-transplant regimen are also considered. Heart transplants are not considered experimental; rather, transplantation has become the treatment of choice for patients who meet the criteria. The patient is not too old for a transplant. The patient's diagnoses and symptoms indicate that the patient may be an appropriate candidate for a heart transplant. Cognitive Level: Comprehension Text Reference: p. 837 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

12. When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. eggs and other high-cholesterol foods. b. canned and frozen fruits. c. fresh or frozen vegetables. d. milk, yogurt, and other milk products.

D Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction. Cognitive Level: Application Text Reference: p. 833 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse take first? a. Palpate the abdomen. b. Assess the orientation. c. Check the capillary refill. d. Auscultate the lung sounds.

D This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this client's teaching? a. Since you only have one kidney, a salt and fluid restriction is required. b. Your therapy will include hemodialysis while you recover. c. Medication will be prescribed to control your high blood pressure. d. You need to avoid participating in contact sports like football.

D ~ Clients with one kidney need to avoid contact sports because the kidneys are easily injured. The client will not be required to restrict salt and fluids, end up on dialysis, or have new hypertension because of the nephrectomy.

A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client's blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take? a. Position the client to lay on the surgical incision. b. Measure the specific gravity of the client's urine. c. Administer intravenous pain medications. d. Assess the rate and quality of the client's pulse.

D ~ The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity & administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

You're assessing your patients during morning rounding. Which patient below is at MOST risk for developing a urinary tract infection? A. A 25 year old patient who finished a regime of antibiotics for strep throat 10 weeks ago. B. A 55 year old female who is post-opt day 7 from hip surgery. C. A 68 year old male who is experiencing nausea and vomiting. D. A 87 year old female with Alzheimer's disease who is experiencing bowel incontinence.

D. A 87 year old female with Alzheimer's disease who is experiencing bowel incontinence.

A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside, what should the nurse assess first? A. Urine output B. Heart rhythm C. Breath sounds D. Blood pressure

D. Blood pressure The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler's position and use other measures to improve gas exchange.

Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death? A. Infection B. Acute rejection C. Immunosuppression D. Cardiac vasculopathy

D. Cardiac vasculopathy Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient's risk of an infection.

A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? A. Taper the patient off his current medications. B. Continue education for the patient and his family. C. Pursue experimental therapies or surgical options. D. Choose interventions to promote comfort and prevent suffering.

D. Choose interventions to promote comfort and prevent suffering. The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not commonly used in the care of hospice patients.

You're caring for a woman with a urinary tract infection who is beginning her first dose of IV antibiotics now. When reading the order, you see you're also supposed to obtain a urine culture. What order should you proceed in? A. Begin to administer the antibiotic then collect a urine culture B. Collect a urine culture and administer antibiotic if culture is positive C. Administer antibiotic, collect urine culture, then send the culture to the lab if the antibiotic doesn't relieve symptoms D. Collect a urine culture, send to the lab, then hang antibiotic

D. Collect a urine culture, send to the lab, then hang antibiotic

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? A. Hypertension, tachycardia, and fever B. Hypotension, bradycardia, and hypothermia C. Restlessness, irritability, and generalized weakness D. Headache, deteriorating level of consciousness, and twitching

D. Headache, deteriorating level of consciousness, and twitching

After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which action should the nurse take first? a. document QRS interval b. notify health care provider c. look at pt current BUN and creatinine d. Check the chart for the most recent blood potassium level.

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

The nurse knows the patient with AKI has entered the diuretic phase when what assessments occur (select all that apply)? A.Dehydration B.Hypokalemia C.Hypernatrimia D.BUN increases E.Serum Creatinine Increases

Dehydration, Hypokalemia Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Therefore the serum BUN and serum creatinine levels also begin to decrease.

The patient was diagnosed with prerenal AKI. The nurse should know that what is most likely the cause of the patient's diagnosis? A.IV tobramycin (Nebcin) B.Incompatible blood transfusion C.Poststreptococcal glomerulonephritis D.Dissecting abdominal aortic aneurysm

Dissecting abdominal aortic aneurysm A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate. Aminoglycoside antibiotic administration, a hemolytic blood transfusion reaction, and poststretpcoccal glomerulonephritis are intrarenal causes of AKI.

A client with heart failure is prescribed an​ angiotensin-converting enzyme​ (ACE) inhibitor. What is the most important side effect that may interfere with​ compliance? Diarrhea Dry cough Rash Visual disturbances

Dry cough Rationale: Clients taking an ACE inhibitor may experience persistent dry cough. They may perceive this as annoying and stop the medication. It is important to advise them to continue with the medication and contact their healthcare provider. ACE inhibitors do not cause​ diarrhea, rash, or visual disturbances.

A 24-year-old female donated a kidney via a laparoscopic donor nephrectomy to a non-related recipient. The patient is experiencing a lot of pain and refuses to get up to walk. How should the nurse handle this situation? A.Have the transplant psychologist convince her to walk. B. Encourage even a short walk to avoid complications of surgery. C.Tell the patient that no other patients have ever refused to walk. D.Tell the patient she is lucky she did not have an open nephrectomy.

Encourage even a short walk to avoid complications of surgery Because ambulating will improve bowel, lung, and kidney function with improved circulation, even a short walk with assistance should be encouraged after pain medication. The transplant psychologist or social worker's role is to determine if the patient is emotionally stable enough to handle donating a kidney, while postoperative care is the nurse's role. Trying to shame the patient into walking by telling her that other patients have not refused and telling the patient she is lucky she did not have an open nephrectomy (implying how much more pain she would be having if it had been open) will not be beneficial to the patient or her postoperative recovery.

A patient with suspected heart failure is being assessed by the nurse. Which set of clinical manifestations indicate that the patient is presenting with left-sided failure? Edema of the feet and legs, anorexia, and nausea Right upper quadrant pain, weakness, nausea, and vomiting Fatigue, dizziness, shortness of breath, and cough Distended veins of the neck and edema of lower limbs

Fatigue, dizziness, shortness of breath, and cough Common clinical manifestations of left-sided heart failure include fatigue, dizziness, shortness of breath, and cough. A patient presenting with symptoms such as anorexia, nausea, right upper quadrant pain, edema of the legs and feet, and distended veins of the neck is showing manifestations consistent with right-sided heart failure.

A nurse is caring for a client with stage IV heart failure. Which nursing diagnosis would be a priority​? Cardiac​ Output, Decreased ​Knowledge, Deficient Activity Intolerance Fluid​ Volume: Excess

Fluid​ Volume: Excess Rationale: Compensatory mechanisms are activated in heart​ failure, specifically neuroendocrine responses. The cascade of decreased cardiac output and decreased renal perfusion stimulates the​ renin-angiotensin system, which stimulates the release of aldosterone from the adrenal cortex and ADH from the posterior pituitary. ANP and BNP are released and blood flow is redistributed to the heart and brain. As a​ result, there is salt and water retention by the kidneys and water excretion is​ inhibited, causing pulmonary​ congestion, renal vasoconstriction and decreased renal​ perfusion, and increased preload and afterload. According to​ Maslow's Hierarchy of​ Needs, oxygenation is the priority need for a client in stage IV heart​ failure, and therefore Fluid​ Volume: Excess is the priority​ diagnosis, since oxygenation is compromised with fluid overload in the lungs. The second one would be Cardiac​ Output, Decreased​, then Activity Intolerance and ​Knowledge, Deficient. ​(NANDA-I ©​ 2014)

Which assessment finding is a consequence of the oliguric phase of AKI? A. Hypovolemia B. Hyperkalemia C. Hypernatremia D.Thrombocytopenia

Hyperkalemia In AKI the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased because of decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI.

The nurse is caring for a patient who has been slowly showing signs of heart failure over the past year. The patient reports recently being very tired, having shortness of breath, being unable to walk their dog, and feeling palpitations. The patient says that they are able to sleep just fine. The nurse suspects the patient is in which stage of heart failure? IV I II III

II Fatigue, shortness of breath, physical limitations due to fatigue, and undisturbed sleep are all marks of stage II heart failure.

A patient states that they can barely get the mail without becoming totally winded and out of breath, but they are able to sleep comfortably at night. The nurse should suspect that the patient is most likely in which stage of heart failure? III IV I II

III In Stage III heart failure, patients show increased physical limitations due to fatigue. Less than normal physical activity results in fatigue, shortness of breath, or palpitations. In stage III, the patient is still able to sleep comfortably at night.

A​ 68-year-old client is admitted to the coronary care unit with complaints of dyspnea at​ rest, orthopnea, weight​ gain, and inability to perform chores in the home due to severe weakness. According to the American Heart​ Association, what stage of heart failure does the nurse​ suspect? II IV I III

IV Stage I​ (mild) heart failure is when the client has no limitations of physical activity and no shortness of breath with normal physical activity. A client with stage II​ (mild) heart failure has some physical limitations due to​ fatigue, shortness of​ breath, or​ palpitations; the client is comfortable at rest. In Stage III​ (moderate), a client has increased physical limitations with less than normal physical activity resulting in​ fatigue, shortness of​ breath, or​ palpitations; the client is comfortable at rest. Stage IV​ (severe) is the most debilitating and the client experiences symptoms of cardiac insufficiency at rest.

The nurse is explaining the phases of cardiac rehabilitation to a patient being prepared for discharge. What is a goal of phase 2 for the patient? Progress from bedrest to ambulation. Perform independent exercises. Bathe independently. Improve psychosocial status.

Improve psychosocial status. Phase 2 of cardiac rehabilitation is characterized by increased activity, improvement of psychosocial status, and treatment of anxiety. Phase 1 has the patient moving from bedrest to providing self-care. An example of this is performing bathing without assistance. In phase 3, the patient is progressing independently in an exercise routine at home.

A nurse is evaluating lab results on a​ 70-year-old client. The nurse notices an increased level of brain natriuretic peptide​ (BNP). What does this​ indicate? Increased left ventricular pressure Decreased vascular congestion Decreased gas exchange in lungs Reduced cardiac workload

Increased left ventricular pressure Rationale: Brain natriuretic peptide​ (BNP) is a hormone released by the heart muscle in response to changes in heart muscle and has been shown to correlate with pressures in the left ventricle and the pulmonary vascular system. As heart failure​ worsens, BNP levels​ rise, and as the heart​ stabilizes, BNP levels decrease. Noting the trend of BNP levels provides information about cardiac output and the​ heart's pumping ability. BNP does not measure cardiac workload or gas exchange in the lungs.

Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. The nurse should know that ultrafiltration in peritoneal dialysis is achieved by which method? A.Increasing the pressure gradient B.Increasing osmolality of the dialysate C.Decreasing the glucose in the dialysate D.Decreasing the concentration of the dialysate

Increasing osmolality of the dialysate Ultrafiltration in peritoneal dialysis is achieved by increasing the osmolality of the dialysate with additional glucose. In hemodialysis the increased pressure gradient from increased pressure in the blood compartment or decreased pressure in the dialysate compartment causes ultrafiltration. Decreasing the concentration of the dialysate in either peritoneal or hemodialysis will decrease the amount of fluid removed from the blood stream.

A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. What is an expected assessment finding for this patient during this early stage of recovery? A.Hypokalemia B. Hyponatremia C.Large urine output D. Leukocytosis with cloudy urine output

Large urine output Patients frequently experience diuresis in the hours and days immediately following a kidney transplant. Electrolyte imbalances and signs of infection are unexpected findings that warrant prompt intervention.

A patient reports dizziness, fatigue, and decreased exercise tolerance. Based on the reported symptoms, the nurse anticipates that the healthcare provider will diagnose the patient as having which classification of heart failure? Systolic Right-sided Diastolic Left-sided

Left-sided Fatigue, dizziness, and decreased exercise tolerance indicate left-sided heart failure. Diastolic, systolic, and right-sided heart failure present with different signs and symptoms.

Which nursing intervention is most appropriate to meet the goal of preserving cardiac output in the patient with heart failure? Place the patient in the high Fowler position. Explain all procedures and tests. Maintain oxygenation of 90% or better. Measure and record intake and output.

Measure and record intake and output. The nurse will measure and record intake and output to monitor the perfusion to the renal system, assessing cardiac output. The nurse will place the patient in shock position, a supine position with the legs elevated to approximately 20 degrees, the abdomen flat, and the head and shoulders elevated higher than the chest (approximately 10 degrees). The nurse will maintain the patient oxygenation of 94% or greater. The nurse will explain all tests and procedures; however, this is more focused on relieving patient anxiety, not preserving cardiac output.

The RN observes an LPN/LVN carrying out all of the following actions while caring for a patient with stage 2 chronic kidney disease. Which action requires the RN to intervene? c. The LPN/LVN gives the iron supplement and phosphate binder with lunch.

Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency.

The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? A.Sodium B.Potassium C. Magnesium D. Phosphorus

Phosphorus Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore administration of calcium should help to reduce a patient's abnormally high phosphorus level, as seen with CKD. PhosLo will not have an effect on sodium, potassium, or magnesium levels.

A patient who is treated at a clinic for low-income and at-risk adults reveals that they use alcohol every day and have been smoking and insufflating cocaine for the past 15 years. The patient reports feeling short of breath recently and states they have been feeling nauseated more frequently than not and, as a result, have not been eating much. With the goal of decreasing risk factors for heart failure, what is the nurse's priority intervention when discussing next steps with the patient? Telling the patient that they should quit using cocaine immediately Advising that the patient participate in a program that offers financial assistance for nutritious food Providing information about rehabilitation and outpatient counseling for substance abuse Suggesting that the patient try to gain access to a health insurance plan with greater coverage so they can have regular medical care

Providing information about rehabilitation and outpatient counseling for substance abuse

A 57-year-old man reports sudden shortness of breath and is producing pink, frothy sputum. Upon physical examination, the nurse notices that his breathing is labored and his respiratory rate is 38 breaths/min. Upon auscultating his chest, the nurse hears fine crackles and faint wheezes throughout his lung fields. Which finding explains the patient's physical assessment findings? Hepatic engorgement Decreased pulmonary hydrostatic pressure Increased myocardial contractility Pulmonary edema

Pulmonary edema

The nurse is caring for a 68-year-old man who had coronary artery bypass surgery 3 weeks ago. If the patient is now is in the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care? A.Provide foods high in potassium. B.Restrict fluids based on urine output. C.Monitor output from peritoneal dialysis D.Offer high protein snacks between meals.

Restrict fluids based on urine output. Fluid intake is monitored during the oliguric phase. Fluid intake is determined by adding all losses for the previous 24 hours plus 600 mL. Potassium and protein intake may be limited in the oliguric phase to avoid hyperkalemia and elevated urea nitrogen. Hemodialysis, not peritoneal dialysis, is indicated in acute kidney injury if dialysis is needed.

The nurse is teaching a patient and their spouse about captopril, an angiotensin-converting enzyme (ACE) inhibitor medication. Which is the most important teaching point for this couple? Take captopril with an antacid. Take captopril 1 hour after meals. Take captopril with meals. Take captopril 1 hour before meals.

Take captopril 1 hour before meals. Captopril (Capoten) should be taken 1 hour before meals to allow for full absorption of the medication into the body. It should be taken at the same time everyday and not with food or antacids, which can affect the absorption process.

A nurse is assessing a client and notices pitting edema in the lower legs. The client has a history of mild congestive heart failure​ (CHF), which is controlled with​ medication, and reports that the swelling has become worse lately. Which could the increased edema​ indicate? The client has increased physical activity. The client has not been compliant with medications. The client has been under stress. The client has a possible progression of CHF.

The client has a possible progression of CHF. ​Rationale: Increased edema in a client with known congestive heart failure is common and can indicate a progression of the​ disease, as perfusion is further compromised. A client with increased edema may need medications adjusted or may need to have further lifestyle management. The nurse should encourage compliance and should stress the importance of avoiding foods and activities that could contribute to edema and decreased tissue perfusion.

Which correctly describes an appropriate expected outcome of an evaluation of patient progress? The patient is able to identify a caregiver who can assist with activities of daily living (ADLs). The patient is able to select healthy, appropriate foods from a menu. The patient is able to prepare at least three separate meals that fit into dietary guidelines. The patient is able to explain what each medication is prescribed for and how each medication works in the body.

The patient is able to select healthy, appropriate foods from a menu. An appropriate expected outcome of patient progress is for a patient to be able to select appropriate foods from a menu. It is not expected that patients will able to prepare several different meals that fit into their diet; cooking may not be a skill they have. Patients should be able to describe the medication they take each day, as well as be aware of the side effects that they should report to the healthcare provider. Expecting more details about complex pharmaceuticals is excessive. The patient should be able to execute ADLs independently as well as be able to identify appropriate increments of rest throughout the day; identifying someone to help them may be helpful, but it is not an expected outcome indicating patient progress.

Which drugs will be used to treat the patient with CKD for mineral and bone disorder (select all that apply)? a. Cinacalcet (Sensipar) b. Sevelamer (Renagel) c. IV glucose and insulin d. Calcium acetate (PhosLo) e. IV 10% calcium gluconate

a, b, d. Cinacalcet (Sensipar), a calcimimetic agent to control secondary hyperparathyroidism; sevelamer (Renagel), a noncalcium phosphate binder; and calcium acetate (PhosLo), a calcium-based phosphate binder are used to treat mineral and bone disorder in CKD. IV glucose and insulin and IV 10% calcium gluconate along with sodium polystyrene sulfonate (Kayexalate) are used to treat the hyperkalemia of CKD.

The patient informs the nurse that he has a "sty" that has been present for some time on the upper eyelid and reports using warm moist compresses with no improvement. What is the best response by the nurse? a. "Go to the pharmacy to get some eye drops." b. "Come in so the ophthalmologist can assess the lesion." c. "The health care provider will need to inject it with an antibiotic." d. "Wash the eyelid margins with baby shampoo to remove the crusting."

a. "Come in so the ophthalmologist can assess the lesion." A chalazion may evolve from a "sty" or hordeolum as it did for this patient. Initial treatment is with warm compresses, but when they are ineffective, the lesion may be surgically removed or injected with corticosteroids. Washing the eyelid margins with baby shampoo is done with blepharitis.

Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? a. Absence of pain or pressure b. Blurred vision in the morning c. Seeing colored halos around lights d. Eye pain accompanied with nausea and vomiting

a. Absence of pain or pressure Primary open-angle glaucoma is typically symptom free, which explains why patients can have significant vision loss before a diagnosis is made unless regular eye examinations are being performed. Primary angle-closure glaucoma manifestations include sudden, excruciating pain in or around the eye, seeing colored halos around lights, and nausea and vomiting.

The nurse is providing discharge instructions for a patient using contact lenses who is diagnosed with bacterial conjunctivitis. What is most important for the nurse to include in the instructions? a. Discard all opened or used lens care products. b. Disinfect contact lenses by soaking in a cleaning solution for 48 hours. c. Put all used cosmetics in a plastic bag for 1 week to kill any bacteria before reusing. d. Disinfect all lens care products with the prescribed antibiotic drops for 1 week after infection.

a. Discard all opened or used lens care products. The patient who wears contact lenses and develops infections should discard all opened or used lens care products and cosmetics to decrease the risk of reinfection from contaminated products. The risk of conjunctivitis is increased with not disinfecting lenses properly, wearing contact lenses too long, or using water or homemade solutions to store and clean lenses.

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. Dysrhythmias may occur with an elevated potassium level and are potentially lethal. Monitor the rhythm while contacting the physician or calling the rapid response team. Vital signs should be checked. Depending on the patient's history and cause of increased potassium, instruct the patient about dietary sources of potassium; however, this would not help at this point. The nurse may want to recheck the value but until then the heart rhythm needs to be monitored.

Priority Decision: During the immediate postoperative care of a recipient of a kidney transplant, what should the nurse 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. Fluid and electrolyte balance is critical in the transplant recipient patient, especially because diuresis often begins soon after surgery. Fluid replacement is adjusted hourly based on kidney function and urine output. Urine-tinged drainage on the abdominal dressing may indicate leakage from the ureter implanted into the bladder and the health care provider should be notified. The donor patient may have a flank or laparoscopic incision(s) where the kidney was removed. The recipient has an abdominal incision where the kidney was placed in the iliac fossa. The urinary catheter is usually used for 2 to 3 days to monitor urine output and kidney function.

A patient is prescribed intravenous (IV) gentamicin after repair of an intestinal perforation. The nurse should assess for which adverse effect of this medication? a. Hearing loss b. Exophthalmos c. Conjunctivitis d. Recurrent fever

a. Hearing loss Aminoglycosides such as gentamicin are drugs that are potentially ototoxic and may cause damage to the auditory nerve. When this drug is used, careful monitoring for hearing and balance problems (e.g., hearing loss, tinnitus, vertigo) is essential. Exophthalmos is related to a symptom of hyperthyroidism. Conjunctivitis is a bacterial or a viral infection of the conjunctiva. Recurrent fever can be related to many issues and is not related to the use of IV gentamicin.

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. Infection is a significant cause of morbidity and mortality after transplantation because the surgery, the immunosuppressive drugs, and the effects of CKD all suppress the body's normal defense mechanisms, thus increasing the risk of infection. The nurse must assess the patient as well as use aseptic technique to prevent infections. Rejection may occur but for other reasons. Malignancy occurrence increases later due to immunosuppressive therapy. Cardiovascular disease is the leading cause of death after renal transplantation but this would not be expected to cause death within the first month after transplantation.

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. Metabolic acidosis occurs in AKI because the kidneys cannot synthesize ammonia or excrete acid products of metabolism, resulting in an increased acid load. Sodium is lost in urine because the kidneys cannot conserve sodium. Impaired excretion of potassium results in hyperkalemia. Bicarbonate is normally generated and reabsorbed by the functioning kidney to maintain acidbase balance.

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. While patients are undergoing hemodialysis, they can perform quiet activities that do not require the limb that has the vascular access. Blood pressure is monitored frequently and the dialyzer monitors dialysis function but cardiac monitoring is not usually indicated. The hemodialysis machine continuously circulates both the blood and the dialysate past the semipermeable membrane in the machine. Graft and fistula access involve the insertion of two needles into the site: one to remove blood from and the other to return blood to the dialyzer.