Unit 3 - Nclex questions

35. A 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 solution in the warmer.

4. Solution for peritoneal dialysis should be warmed to body temperature in a warmer or with a heating pad; do not use the microwave. Cold dialysate increases discomfort. Assessment for a bruit and thrill is necessary with hemodialysis when the client has a fistula, graft, or shunt. An indwelling urinary catheter is not required for this procedure. The nurse should position the client in a supine or low Fowler's position.

48. The client receives heparin while receiv- ing hemodialysis. The nurse explains the rationale supporting anticoagulation by making which of the following statements? ■ 1. "Regional anticoagulation is achieved by putting heparin in the dialysis machine and protamine sulfate, which reverses the antico- agulation, in the client." ■ 2. "You will receive warfarin sodium (Couma- din) to maintain anticoagulation between treatments." ■ 3. "Heparin does not enter the body, so there is no risk of bleeding." ■ 4. "Clotting time is seriously prolonged for sev- eral hours after each treatment."

48. 1. Regional anticoagulation can be achieved by infusing heparin in the dialyzer and protamine sulfate, its antagonist, in the client. Warfarin sodium (Coumadin) is not used in dialysis treatment. There is some risk of bleeding; however, clotting time is monitored carefully. The client's clotting time will not be seriously affected, although some rebound effect may occur.

Which nursing assessment is most accurate in determining the patency of a client's newly placed left forearm internal arteriovenous (AV) fistula for hemodialysis? 1. Feeling for a bruit on the left forearm 2. Palpating for a thrill over the fistula 3. Aspirating blood from the fistula every 8 hours 4. Checking the client's distal pulses and circulation

ANSWER: 2 An AV fistula is created by the anastomosis of an artery to a vein. A thrill is the arterial blood rushing into the vein. Its presence indicates that the fistula is not occluded. Bruits are auscultated, not palpated. Aspirating for blood is unnecessary and can damage the fistula because it takes 4 to 6 weeks to mature. Although checking circulation, motion, and sensation (CMS) is important to assess circulation to the hand, it does not provide information about the patency of the fistula. ➧ Test-taking Tip: Focus on the issue of patency of the fistula and the key words "most accurate" to answer this question.

931. A nurse is concerned that a client receiving peritoneal dialysis may be experiencing peritonitis. Which find- ing noted on the nurse's assessment supported this concern? 1. Abdominal numbness 2. Cloudy dialysis output 3. Radiating sternal pain 4. Decreased white blood cells

ANSWER: 2 Manifestations of peritonitis include cloudy dialysate, fever, abdominal tenderness, abdominal pain, general malaise, nausea, and vomiting. The client would experience abdominal tenderness and pain, not numbness or sternal pain. White blood cells (WBCs) would increase in the presence of an infection. ➧ Test-taking Tip: Focus on the issue of peritonitis and use the process of elimination. Eliminate option 4 because WBCs should be elevated. Eliminate 1 and 3 because they are uncharacteristic of peritonitis.

926. Which notation should a nurse document as an appro- priate outcome in the plan of care for a client with chronic renal failure? 1. Consumption of three large meals daily without nausea 2. Daily weight gain of no more than 3 pounds 3. Reduced serum albumin levels within 1 week 4. Absence of bleeding

ANSWER: 4 The client with chronic renal failure is at risk for bleeding because of impaired platelet function. The absence of bleeding is an appropriate client outcome. The client with chronic renal failure has the potential for imbalanced nutrition due to anorexia, nausea, and stomatitis secondary to the effects of urea excess on the gastrointestinal system. The client should consume small, frequent meals, not large meals. The client with chronic renal failure is at risk for fluid volume excess because of the kidneys' in- ability to excrete water. A weight gain indicates fluid retention. The client with chronic renal failure has the potential for imbalanced nutrition be- cause of a protein-restricted diet. Serum albumin levels should be within normal limits. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to identify option 4 as the correct answer to the question.

52. The client has received a kidney transplant. Which assessment would warrant immediate intervention by the nurse? 1. Fever and decreased urine output. 2. Decreased creatinine and BUN levels. 3. Decreased serum potassium and calcium. 4. Bradycardia and hypotension.

Answer = 1 1. Oliguria, fever, increasing edema, hypertension, and weight gain are signs of organ rejection. 2. A decrease in serum creatinine and BUN would indicate the transplanted kidney is functioning well. 3. Potassium and calcium are not monitored for rejection. 4. The client with a fever might have tachy- cardia. Hypertension is a sign of rejection.

49. The mother of a 20-year-old African American male client receiving dialysis asks the nurse, "My son has been on the transplant list longer than that white woman. Why did she get the kidney?" Which statement is the nurse's best response? 1. "The woman was famous, and so more people will donate organs now." 2. "I understand you are upset your son is ill. Would you like to talk?" 3. "No one knows who gets an organ. You just have to wait and pray." 4. "The tissues must match or the body will reject the kidney and it will be wasted."

Answer = 4 1. There is a feeling during times of stress that organs may be distributed unfairly. Tissue and organ banks use the United Network of Organ Sharing (UNOS) to be as fair as pos- sible in the allocation of organs and tissues. Organs will be given to the best match for the organ in the community where the donor dies. If no match is found in that area, then the search for an HLA match will be expanded to other areas of the country. The recipient is chosen on the basis of HLA match, not fame or fortune. 2. The client is asking for information, which the nurse should provide. 3. There is a definite method of allocation of organs. 4. There are 27 known human leukocyte antigens (HLAs). HLAs have become the principal histocompatibility system used to match donors and recipients. The greater the number of matches, the less likely the client will reject the organ. Different races have different HLAs.

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

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

A client had a lithotripsy to treat renal calculi. The client is having ureteral spasms and hematuria. What should the nurse do? Select all that apply. Strain all urine. Apply a heating pad to the lower back area. Contact the health care provider (HCP) to report hematuria. Encourage fluid intake of 1,000 ml/day. Assess pain level.

Correct response: Strain all urine. Apply a heating pad to the lower back area. Assess pain level. Following lithotripsy, the nurse strains all urine to collect and identify stone composition. Providing heat to the flank area may be helpful to relieve muscle spasms when renal colic is present; the nurse assesses the client's pain level and administers analgesics as needed. Hematuria is common after lithotripsy, and it is not necessary to notify the HCP. The nurse should promote a fluid intake of at least 2,000 ml/day to flush stones and clots through the urinary tract.

The client asks the nurse, "How did I get this urinary tract infection?" The nurse should explain that in most instances, cystitis is caused by: congenital strictures in the urethra. an infection elsewhere in the body. urinary stasis in the urinary bladder. an ascending infection from the urethra.

Correct response: an ascending infection from the urethra. Explanation: Although various conditions may result in cystitis, the most common cause is an ascending infection from the urethra. Strictures and urine retention can lead to infections, but these are not the most common cause. Systemic infections are rarely causes of cystitis.

A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by: disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. draining urine from the drainage bag into a sterile container. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.

Correct response: wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. Explanation: Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there's no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect.

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Question: Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? (select all that apply) Correct Answers: Client on the second post operative day who needs pain medication before dressing changes Client who is reporting pain at the site of a peripheral IV line Client with a kidney stone who needs frequent PRN pain medication Explanation: Predictable & stable clients B, E, F are who should be assigned to a newly graduated RN. Clients A, C, D - not predictable or stable and new client teaching;

A possible outcome for the client being treated with spironolactone for nephrotic syndrome is? A: Hyponatremia B: Hyperkalemia C: Hypercalcemia D: Hypophosphatemia

Question: A possible outcome for the client being treated with spironolactone for nephrotic syndrome is? Correct Answer: Hyperkalemia Explanation: Spironolactone is K sparing diuretic

A client is at risk for acute pyelonephritis. The nurse should instruct the client about which health promotion behaviors that will be most effective in preventing pyelonephritis? Wash the perineum with warm water and soap, cleaning from front to back. Treat fungal infections such as athlete's foot immediately. Have a pneumonia immunization to prevent streptococcal infection. Treat skin lesions with antibiotics, and cover any open lesions.

Wash the perineum with warm water and soap, cleaning from front to back. Explanation: Acute pyelonephritis usually begins with a bacterial infection of the lower urinary tract via the ascending urethral route; most infections are due to gram-negative bacilli, such as E. coli, normally found in the GI tract. Thorough perineal care using soap and warm water, and cleansing from front to back, decreases the likelihood that organisms will be introduced into the urinary tract and ascend upward toward the kidneys. Although preventing and treating all infections are appropriate, fungal infections from the feet and bacterial infections in the throat or skin are less likely to be immediate sources of infection causing pyelonephritis.

932. A nurse is admitting a client with possible renal trauma after a motor vehicle accident. When caring for this client, which actions should be taken by the nurse? Prioritize the nurse's actions by numbering each action from the highest priority (1) to the lowest priority (5). ____ Teach the client signs of a urinary tract infection (UTI) ____ Palpate both flanks for asymmetry ____ Assess for pain in the flank area ____ Prepare the client for a CT scan ____ Inspect the abdomen and the urethra for gross bleeding

___5_ Teach the client signs of a urinary tract infection (UTI) __3__ Palpate both flanks for asymmetry __1__ Assess for pain in the flank area __4__ Prepare the client for a CT scan _2___ Inspect the abdomen and the urethra for gross bleeding First assess for pain. Unrelieved pain can prolong the stress response. A nurse should treat pain before the physical exam, sending the client for a test, or teaching. Next, the nurse would inspect the abdomen and urethra for gross bleeding. Third, the flanks should be palpated for asymmetry. If gross bleeding is present, the abdomen should not be palpated. Once the physical examination is completed, the client should be prepared for a computed tomography (CT) exam. The least priority would be to teach the client about signs of a UTI. ➧ Test-takingTip: Use the nursing process and the physical assessment process to prioritize the nursing actions. Assessment is the first step in the nursing process. Look for the key word "assess." Inspection should occur before palpation because the findings could lead to deciding not to palpate because it could cause harm. Use the other steps of the nursing process to prioritize the remaining items.

37. Which of the following is the most common initial manifestation of acute renal failure? ■ 1. Dysuria. ■ 2. Anuria. ■ 3. Hematuria. ■ 4. Oliguria.

4. Oliguria is the most common initial symp- tom of acute renal failure. Anuria is rarely the initial symptom. Dysuria and hematuria are not associated with acute renal failure.

43. The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate? ■ 1. A gelatin dessert. ■ 2. Yogurt. ■ 3. An orange. ■ 4. Peanuts.

1. Gelatin desserts contain little or no potas- sium and can be served to a client on a potassium- restricted diet. Foods high in potassium include bran and whole grains; most dried, raw, and frozen fruits and vegetables; most milk and milk products; chocolate, nuts, raisins, coconut, and strong brewed coffee.

40. The client's serum potassium level is ele- vated in acute renal failure, and the nurse adminis- ters sodium polystyrene sulfonate (Kayexalate). This drug acts to: ■ 1. Increase potassium excretion from the colon. ■ 2. Release hydrogen ions for sodium ions. ■ 3. Increase calcium absorption in the colon. ■ 4. Exchange sodium for potassium ions in the colon.

4. Polystyrene sulfonate, a cation-exchange resin, causes the body to excrete potassium through the gastrointestinal tract. In the intestines, particu- larly the colon, the sodium of the resin is partially replaced by potassium. The potassium is then eliminated when the resin is eliminated with feces. Although the result is to increase potassium excre- tion, the specific method of action is the exchange of sodium ions for potassium ions. Polystyrene sulfonate does not release hydrogen ions or increase calcium absorption.

A nurse evaluates that a client is in the recovery phase of acute renal failure (ARF). Achievement of which outcomes supports the nurse's conclusion? SELECT ALL THAT APPLY. 1. Increased urine specific gravity 2. Increased serum creatinine level 3. Decreased serum potassium level 4. Absence of nausea and vomiting 5. Absence of muscle twitching

ANSWER: 1, 3, 4, 5 Urine specific gravity increases because of the kidneys' ability to con- centrate urine and excrete electrolytes. Potassium is decreased because of the kidneys' ability to excrete potassium. Nausea, vomiting, and di- arrhea are common in ARF because of accumulation of nitrogenous wastes. An absence of these indicates that the client is in the recovery phase of ARF. Neurologically, the client in renal failure may have mus- cle twitching, drowsiness, headache, and seizures because of the elec- trolyte imbalances and accumulation of metabolic wastes. In the re- covery period, the client should not have muscle twitching. The client should have a decreased, not increased, serum creatinine level in the recov- ery period. ➧ Test-taking Tip: Look for signs that show improvement, thus eliminating option 2. Avoid reading into the question. Muscle twitching could occur from other problems, but consider if it can also occur with ARF.

This complication is found mainly in Type 2 diabetics? Diabetic Ketoacidosis Hyperglycemic Hyperosmolar Nonketotic Syndrome

Diabetic Ketoacidosis

The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include: Kussmaul's respirations. excessive hunger. dry, flaky skin. high blood pressure.

Kussmaul's respirations. Explanation: The client with diabetic ketoacidosis exhibits Kussmaul's respiration, as well as flushed skin, dry mouth, urinary frequency, hyperglycemia, and ketonuria. Excessive hunger and high blood pressure are not associated with diabetic ketoacidosis.

Which of the following is not a sign or symptom of Diabetic Ketoacidosis? Positive Ketones in the urine Oliguria Polydipsia Abdominal Pain

Oliguria Oliguria means low urinary output....in DKA you have high urinary ouput (POLYURIA).

How does HHS differ from DKA? A: HHS has the same onset, higher blood sugars, and more dehydration than DKA. B: HHS has a slower onset, lower blood sugars, and less dehydration than DKA. C: HHS has a slower onset, much higher blood sugars, and more profound dehydration than DKA. D: HHS has the same onset as and lower blood sugars than DKA, but no dehydration.

Question: How does HHS differ from DKA? Correct Answer: HHS has a slower onset, much higher blood sugars, and more profound dehydration than DKA.

The nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse should be alert for which signs and symptoms? Select all that apply. A: Fractures B: Cardiac arrhythmias C: Constipation D: Trousseau sign D: Drowsiness and lethargy F: Decreased clotting time

Question: The nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse should be alert for which signs and symptoms? Select all that apply. Correct Answers: Fractures Cardiac arrhythmias Trousseau sign Explanation: S/S of hypocalcemia include Trousseau, cardiac arrhythmias, diarrhea, increased clotting times, anxiety, irritability. Brittle bones and pathologic fractures are also a problem with hypocalcemia.

What is released by the pituitary when a hyperosmolar state is present? A: Renin B: Calcitonin C: Prostaglandin D: Antidiuretic hormone (ADH)

Question: What is released by the pituitary when a hyperosmolar state is present? Correct Answer: Antidiuretic hormone (ADH) Explanation: ADH is secreted by pituitary - hyperosmolar state would require the retention of more water to reduce the s. osm.

A client is admitted to the recovery room after cystoscopy with biopsy. Before the nurse can discharge the client, the nurse should be sure the client: has a bowel movement. has received the first dose of pain medication. has voided. has no blood in the urine.

has voided. Explanation: The nurse should verify that the client has voided prior to discharge in order to evaluate bladder function. Bowel function is not expected to be affected by this procedure. There may not be a need for pain medication immediately postprocedure and before discharge, but the nurse should assess the client's pain status and inform the client about the use and side effects of the medication. It is normal for the client to have hematuria because of the procedure.

The nurse teaches the client with a urinary diversion to attach the appliance to a standard urine collection bag at night. The most important reason for doing this is to prevent: urine reflux into the stoma. appliance separation. urine leakage. the need to restrict fluids.

urine reflux into the stoma. Explanation: The most important reason for attaching the appliance to a standard urine collection bag at night is to prevent urine reflux into the stoma and ureters, which can result in infection. Use of a standard collection bag also keeps the appliance from separating from the skin and helps prevent urine leakage from an overly full bag, but the primary purpose is to prevent reflux of urine. A client with a urinary diversion should drink 2,000 to 3,000 mL of fluid each day; it would be inappropriate to suggest decreasing fluid intake.

929. A nurse is initiating peritoneal dialysis for a client with renal failure. During the infusion of the dialysate, the client reports abdominal pain. Which intervention by the nurse is most appropriate? 1. Stopping the dialysis 2. Slowing the infusion 3. Asking if the client is constipated 4. Explaining that the pain will subside after a few exchanges

ANSWER: 4 Peritoneal irritation, from the inflow of the dialysate, commonly causes pain during the first few exchanges. The pain usually subsides within 1 to 2 weeks. Positioning the client supine in a low-Fowler's posi- tion reduces intra-abdominal pressure. The infusion should not be stopped or slowed, because it is peritoneal irritation causing the pain. The pain should be treated. Constipation may cause slowing and the client may feel pressure, but not pain, during inflow of the dialysate solution. ➧ Test-taking Tip: Use the process of elimination, ruling out options 1 and 2 because these are similar actions.

55. The nurse is caring for a client who received a kidney transplant from an unrelated cadaver donor. Which interventions should be included in the plan of care? Select all that apply. 1. Collect a urine culture every other day. 2. Prepare the client for dialysis three (3) times a week. 3. Monitor urine osmolality studies. 4. Monitor intake and output every shift. 5. Check abdominal dressing every four (4) hours.

Answer = 1 and 2 1. Urine cultures are performed fre- quently because of the bacteriuria present in the early stages of transplantation. 2. A cadaver kidney may have undergone acute tubular necrosis and may not function for two (2) to three (3) weeks, during which time the client may expe- rience anuria, oliguria, or polyuria and require dialysis. 3. Serum creatini Assessment is always the nurse's responsi- bility and cannot be delegated. Hourly outputs are monitored to determine kid- ney function. 4. Hourly outputs are monitored and compared with the intake of fluids. 5. The dressing is a flank dressing. TEST-TAKING HINT: The test taker should notice time frames. Anytime a specific time reference is provided, the test taker must determine if the time frame is the appropriate interval for performing the activity. In option "4," "every shift" is not appropriate.

A nurse is about to admit a client to the medical surgical unit directly from the healthcare provider's office. Upon assessment, the nurse notes that the client has significant periorbital edema. Laboratory values indicate the presence of proteinuria and hypoproteinemia. Which of the following is the nurse's priority action?

Correct response: Strict intake and output assessment and documentation Explanation: Symptoms are highly suggestive of glomerulonephritis. Clients require strict intake and output are generally placed on a high protein diet. Monitoring of laboratory values is good nursing practice overall, but not the priority with this diagnosis. Ambulation is not the priority, as client requires rest.

The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply. Thirst Palpitations Diaphoresis Slurred speech Hyperventilation

Palpitations Diaphoresis Slurred speech Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed.

A client with nephrotic syndrome asks the nurse why the blood test reveals elevated lipids. What is the best response by the nurse? A: "You had just eaten a fatty meal, so the lipids might be falsely elevated." B: "It's not unusual to see elevated lipids because of the dietary habits of today." C: "With the loss of protein, the liver is stimulated and is making more lipids." D: "Your blood is very concentrated because of the edema, so the lipids are falsely elevated."

Question: A client with nephrotic syndrome asks the nurse why the blood test reveals elevated lipids. What is the best response by the nurse? Correct Answer: "With the loss of protein, the liver is stimulated and is making more lipids." Explanation: the liver is making more lipids due to the massive loss of protein.

The pediatric CN is making assignments for the next shift. Which client is most appropriate to assign to an experienced LVN / LPN? A : 1-year-old with severe combined immunodeficiency disease who is scheduled to receive chemotherapy B: 2-year-old with ITP who has orders for a platelet transfusion C: 3-year-old who has chronic graft-versus-host disease and has stool incontinence D: 6-year-old who received chemotherapy last week and is now admitted with lethargy and a temperature of 101 degrees F.

Question: The pediatric CN is making assignments for the next shift. Which client is most appropriate to assign to an experienced LVN / LPN? Correct Answer: 3-year-old who has chronic graft-versus-host disease and has stool incontinence Explanation: Chronic vs acute

During hemodialysis, the nurse notes that the client becomes confused and restless. The client reports a headache and nausea and has generalized muscle twitching. This can be prevented by doing what? A: Slow the rate of solute removal during dialysis. B: Ensure the client is warm during dialysis. C: Administer antibiotics before dialysis. D: Obtain an accurate weight before dialysis treatment.

Question: During hemodialysis, the nurse notes that the client becomes confused and restless. The client reports a headache and nausea and has generalized muscle twitching. This can be prevented by doing what? Correct Answer: Slow the rate of solute removal during dialysis. Explanation: The client is experiencing dialysis disequilibrium syndrome and this can be prevented by slowing the rate of solute removed during the HD treatment.

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? bradycardia, and somnolence Sweating, tremors, and tachycardia Dry skin, Bradycardia, thirst, and anxiety Polyuria, polydipsia, and polyphagia

Sweating, tremors, and tachycardia Explanation: Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus.

927. A nursing assistant reports to a nurse that a client di- agnosed with chronic renal failure has "white crys- tals" and dry, itchy skin. Based on this information, the nurse should instruct the nursing assistant to: 1. apply the prescribed antipruritic cream to the client's skin. 2. offer the client a glass of warm milk to drink. 3. bathe the client in tepid water. 4. assess the client's serum creatinine levels.

ANSWER: 3 Bathing the client in cool water will remove crystals, decrease itching, and promote client comfort. The crystals (uremic frost) and itching are from irritating toxins and deposits of calcium phosphate precipitates on the skin. Although an antipruritic cream could be applied to relieve itching, applying the medication would not be within the scope of practice of a nursing assistant. Fluid intake is usually restricted for the client with chronic renal failure. Assessment is not within the scope of practice of a nursing assistant. Knowing the serum creatinine levels will not address the problem of the uremic frost and itchy skin. ➧ Test-taking Tip: Focus on the problem, the "white crystals" and dry, itchy skin and delegate appropriately. Knowing the scope of practice for a nursing assistant and interventions for uremic frost and pruritis will help answer this question.

919. A nurse reviews the laboratory report of a client with acute renal failure (ARF) and notes that the serum potassium level is 6.8 mEq/L. Which medication should the nurse plan to administer specifically to protect the heart from the high potassium levels? 1. Erythropoietin 2. Regular insulin 3. 50% dextrose 4. Calcium gluconate

ANSWER: 4 Calcium gluconate raises the threshold for cardiac muscle excitation, thereby reducing the incidence of life-threatening dysrhythmias that can occur with hyperkalemia. Erythropoietin triggers the production of red blood cells by bone marrow. It is used to treat anemia, which is com- mon in renal failure. Regular insulin, along with 5% to 50% dextrose, forces the potassium into the cells; temporarily lowering serum potassium levels. ➧ Test-taking Tip: Note the key word "specifically." Read the question carefully and use the process of elimination to find the medication that protects the heart.

Which hospitalized client is at highest risk for catheter associated urinary tract infection (CAUTI)? client who had one course of antibiotic therapy client with a family history of UTIs client with a urinary calculus client with diabetes mellitus

Correct response: client with diabetes mellitus Explanation: Clients who are immunosuppressed, have diabetes mellitus, or have undergone multiple courses of antibiotic therapy are prone to bacterial, fungal, and parasitic infections. Taking one course of antibiotic therapy or having a family history of UTIs does not make a client at high risk for development of a UTI. A predisposing factor for a UTI is ongoing problems of urinary calculi; one calculus would not place a client at high risk.

A client has been admitted with AKI. What should the nurse do? Select all that apply. A: Contact the hemodialysis unit B: Take vital signs C: Elevate the head of bed 30-45 degrees D: Establish IV access E: Call the admitting physician for orders

Question: A client has been admitted with AKI. What should the nurse do? Select all that apply. Correct Answers: Take vital signs Elevate the head of bed 30-45 degrees Establish IV access Call the admitting physician for orders Explanation: vital signs important with new admission and ongoing assessment; HOB elevation to help with respiratory / breathing. IV access for fluids / medications; Physician should be notified for orders. No need to call HD unit, as there is not enough information to tell us if this client will need dialysis treatment or not.

The parents of a child diagnosed with Acute Kidney Injury asks the nurse why peritoneal dialysis was selected instead of hemodialysis. Which response by the nurse is best? A : "Hemodialysis is not used in the pediatric population." B: "Peritoneal dialysis has no complications, so it is a treatment used often." C: "Peritoneal dialsysis removes fluid at a slower rate than hemodialysis, so complications are minimized." D: "Peritoneal dialysis is much more efficient than hemodialysis."

Question: The parents of a child diagnosed with Acute Kidney Injury asks the nurse why peritoneal dialysis was selected instead of hemodialysis. Which response by the nurse is best? Correct Answer: "Peritoneal dialsysis removes fluid at a slower rate than hemodialysis, so complications are minimized." Explanation: PD does remove fluid at a slower rate, so complications are reduced. HD is used in pedi, but not generally in those weighing less than 20 kg due to CV and access challenges. PD does have complications - can you name them? HD is more efficient than PD.

Which task is appropriate for the nurse to delegate to an experienced UAP? A: Obtain a 24-hour diet recall from a client recently admitted with anorexia nervosa. B: Obtain a clean-catch urine specimen from a client suspected of having a urinary tract infection. C: Observe the amount and characteristics of the returns from a continuous bladder irrigation for a client after a transurethral resection of the prostate. D: Observe a client newly diagnosed with diabetes mellitus practice injection techniques using an orange.

Question: Which task is appropriate for the nurse to delegate to an experienced UAP? Correct Answer: Obtain a clean-catch urine specimen from a client suspected of having a urinary tract infection. Explanation: diet recall, monitoring bladder irrigation, & return demonstration fall under assessment for the nursing scope of practice. The UAP can obtain the urine specimen.

The nurse collects a urine specimen from a client for a culture and sensitivity analysis. What should the nurse do next? Send the specimen with the next pickup. Send the specimen the next time an unlicensed assistive personnel (UAP) is available. Send the specimen to the laboratory immediately. Store the specimen in the refrigerator until it can be sent to the laboratory.

Send the specimen to the laboratory immediately. Explanation: A specimen for culture and sensitivity should be sent to the laboratory promptly so that a smear can be taken before organisms start to grow in the specimen.