Complex Exam 2

A client with chronic renal failure receives hemodialysis three times a week. In order to protect the fistula, the nurse should: 1. Take the blood pressure in the arm with the fistula 2. Report the loss of a thrill or bruit on the arm with the fistula 3. Maintain a pressure dressing on the shunt 4. Start a second IV in the arm with the fistula

2. Report the loss of a thrill or bruit on the arm with the fistula

A client has been admitted with acute renal failure. What should the nurse do? SATA 1. Elevate the head of the bed 30-45 degrees 2. Take vital signs 3. Establish an IV access site 4. Call the admitting healthcare provider for prescriptions 5. Contact the hemodialysis unit

2. Take vital signs 4. Call the admitting healthcare provider for prescriptions

A client developed cardiogenic shock after suffering a severe myocardial infarction and failure. The client now has developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. The nurse should base the response on the knowledge that there was: 1. A decrease in the blood flow through the kidneys 2. An obstruction of urine flow from the kidneys 3. A blood clot formed in the kidney 4. Structural damage to the kidney resulting in acute tubular necrosis

1. A decrease in the blood flow through the kidneys (pre- renal ARF)

The client with acute renal failure is recovering and asks the nurse, "Will my kidneys ever function normally again?" The nurse's response is based on knowledge that the client's status will most likely: 1. Continue to improve over a period of weeks 2. Result in the need for permanent hemodialysis 3. Improve only if the client receives a renal transplant 4. Result in end-stage renal failure

1. Continue to improve over a period of weeks

A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with liver failure? 1. Hypoalbuminemia 2. Increased capillary permeability 3. Abnormal peripheral vasodilation 4. Excess rennin release from the kidneys

1. Hypoalbuminemia

The client in acute renal failure has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of this client? 1. Use the unaffected arm for blood pressure 2. Draw blood from the cannula for routine laboratory work 3. Percuss the cannula for bruits each shift 4. Inject heparin into the cannula each shift

1. Use the unaffected arm for blood pressure measurements

A client with end-stage renal failure has an internal arteriovenous fistula in the left arm for vascular access during hemodialysis. What should the nurse instruct the client to do? SATA 1. Remind healthcare providers to draw blood from veins on the left side 2. Avoid sleeping on the left arm 3. Wear wristwatch of the right arm 4. Assess finger on the left hand for warmth 5. Obtain blood pressure from the left arm

2. Avoid sleeping on the left arm 3. Wear wristwatch on the right arm 4. Assess finger on the left hand for warmth

During the peritoneal dialysis, the nurse observes that the solution draining from the client's abdomen is consistently blood tinged. The client has a permanent dialysis catheter in place. The nurse should recognize that the bleeding: 1. Is expected with a permanent peritoneal catheter 2. Indicates abdominal blood vessel damage 3. Can indicate kidney damage 4. Is caused by too-rapid infusion of the dialysate

2. Indicates abdominal blood vessel damage

The client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should: 1. Assess the dialysis access for a bruit and thrill 2. Insert an indwelling urinary catheter and drain all urine from the bladder 3. Ask the client to turn toward the left side 4. Warm the dialysis solution in the warmer

4. Warm the dialysis solution in the warmer

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client. SATA A. Elevate the head of the bed to 90 degrees B. Loosen constrictive clothing C. Use fan to reduce diaphoresis D. Assess for bladder distention and bowel impaction E. Administer antihypertensive medications F. Place the client in a supine position with legs elevated

A. Elevate the head of the bed to 90 degrees B. Loosen constrictive clothing D. Assess for bladder distention and bowel impaction E. Administer antihypertensive medications

A client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is no pain. How will the nurse categorize this injury? A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Superficial

A. Full-thickness

The client has experienced an electrical injury with an entrance would on the left hand and an exit wound site on the left foot. What is the priority assessment data that should be obtained from this client immediately on admission? A. Urine output B. Heart rate and rhythm C. Orientation to time, place and situation D. Sensation in all extremities

B. Heart rate and rhythm

You are caring for a client who is undergoing peritoneal dialysis. You note the color of the returned fluid appears cloudy and slightly pink-tinged. What is your best action? A. Irrigate the peritoneal catheter B. Stop the dialysis flow and notify the healthcare provider C. Document the finding as the only action D. Change the dialysate

B. Stop the dialysis flow and notify the healthcare provider

When caring for a client with a head and neck trauma following a vehicular crash, the nurse's initial action is to? A. Perform oral and nasal suctioning B. Provide oxygen therapy C. Initiate intravenous access D. Immobilize the cervical area

D. Immobilize the cervical area

What is the best way to check for patency of the arteriovenous fistula for hemodialysis? A. Pinch the fistula and note the speed of filling on release B. Pinch the fistula and note the speed of filling on release C. Check for capillary refill of the nail beds on that extremity D. Palpate the fistula throughout its length to assess for a thrill

D. Palpate the fistula throughout its length to assess for a thrill