AHIV Exam 2

The nurse provides home care instructions to a client undergoing hemodialysis with regard to care of a newly created arteriovenous (AV) fistula. Which client statement indicates that teaching was effective? 1."I should check the fistula every day by feeling it for a vibration." 2."I am glad that the laboratory will be able to draw my blood from the fistula." 3."I should wear a shirt with tight arms to provide some compression on the fistula." 4."I should check my blood pressure in the arm where I have my fistula every week."

1

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1.Restricting fluids 2.Placing a pillow under the knees 3.Encouraging active range-of-motion exercises 4.Applying a heating pad to the lower extremities

3

The nurse is analyzing the post hemodialysis laboratory test results for a client with chronic kidney disease. The nurse interprets that the dialysis is having an expected but nontherapeutic effect if which value is decreased? 1.Potassium 2.Creatinine 3.Phosphorus 4.Red blood cell (RBC) count

4 Hemodialysis typically lowers the amounts of fluid, sodium, potassium, urea nitrogen, creatinine, uric acid, magnesium, and phosphate levels in the blood. Hemodialysis also worsens anemia because RBCs are lost during dialysis from blood sampling and anticoagulation and from residual blood left in the dialyzer. Although all of these results are expected, only the lowered RBC count is nontherapeutic and worsens the anemia already caused by the disease process.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1.Slow, deep respirations 2.Rapid, deep respirations 3.Paradoxical respirations 4.Pain, especially with inspiration

4

A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse should take which action? 1.Make sure that the client is not lying on the ventilator tubing. 2.Determine if there are any disconnections in the ventilator tubing. 3.Check to see if the client is biting on the endotracheal tube (ETT). 4.Auscultate the lungs to determine if the client needs to be suctioned.

2

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1.A 25-year-old woman with diabetic ketoacidosis 2.A 65-year-old man out of bed 1 day after prostate resection 3.A 73-year-old woman who has just had pinning of a hip fracture 4.A 38-year-old man with pulmonary contusion sustained in an automobile crash

3

The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? 1.Muscle weakness in the arms and legs 2.A temperature of 98.6º F (37º C), decreased from 99.0º F (37.2º C) 3.A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg 4.A heart rate of 80 beats/minute, decreased from 85 beats/minute

3 Complications of mechanical ventilation include the following: hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; pneumothorax or subcutaneous emphysema as a result of positive pressure; gastrointestinal alterations such as stress ulcers; malnutrition if nutrition is not maintained; infections; muscular deconditioning; and ventilator dependence or inability to wean. Some muscle weakness is expected. Options 1, 2, and 4 present normal assessment findings.

The nurse is planning a teaching session with a client who has chronic kidney disease (CKD) about managing the condition between dialysis treatments. The nurse should plan to include the instruction that weight gain between dialysis treatments should be ideally what value? 1.11 to 13 lb (5 to 6 kg) 2.4.5 to 9 lb (2 to 4 kg) 3.2 to 3 lb (1 to 1.5 kg) 4.1 to 2 lb (0.5 to 1.0 kg)

3 Limiting weight gain to 2 to 3 lb (1 to 1.5 kg) between dialysis treatments helps prevent the hypotension that occurs with the removal of large volumes of fluid during dialysis. The nurse instructs the client in how to manage daily fluid allotment to assist the client in staying within a low fluid intake range to prevent excess weight gain. Options 1, 2, and 4 are incorrect.

A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies? 1.Administration of plasma expanders, low-flow oxygen, and suctioning 2.Administration of bronchodilators, intubation, and mechanical ventilation 3.Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure 4.Administration of antihypertensives, high-flow oxygen, and continuous positive airway pressure mask

3 Respiratory failure is the most common cause of death after fat embolus. The client may be intubated and mechanically ventilated with positive end-expiratory pressure to treat the significant hypoxemia and pulmonary edema. The use of corticosteroids is controversial. When given, these agents are used to treat inflammatory lung reactions and control cerebral edema. The remaining options are incorrect.

The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least 3 ribs. What is the nurse's priority action for this victim? 1.Assist the victim to sit up. 2.Remove the victim's shirt. 3.Turn the victim onto the side opposite the flail chest. 4.Apply firm but gentle pressure with the hands to the flail segment.

4 If flail chest is present, the nurse applies firm but gentle pressure to the flail segments of the ribs to stabilize the chest wall, which will ultimately help the victim's respiratory status. The nurse does not move an injured client for fear of worsening an undetected spinal injury. Removing the victim's shirt is of no value in this situation and could in fact result in chilling the victim, which is counterproductive. Injured clients should be kept warm until help arrives at the scene.

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1.Right pneumothorax 2.Pulmonary embolism 3.Displaced endotracheal tube 4.Acute respiratory distress syndrome

1

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? 1.Do nothing because this is an expected finding. 2.Check for an air leak because the bubbling should be intermittent. 3.Increase the suction pressure so that the bubbling becomes vigorous. 4.Clamp the chest tube and notify the primary health care provider immediately.

2

The nurse is caring for a client with acute kidney injury (AKI). The nurse should test the client's urine for proteinuria to determine which type of AKI? 1.Prerenal 2.Intrinsic 3.Atypical 4.Postrenal

2 In intrinsic failure, there is a fixed specific gravity and the urine tests positive for proteinuria. In prerenal failure, the specific gravity is high, and there is very little or no proteinuria. In postrenal failure, there is a fixed specific gravity and little or no proteinuria. There is no disorder known as atypical renal failure.

The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1.Replace the chest tube system. 2.Obtain a pulse oximetry reading. 3.Call the primary health care provider. 4.Place the client in a Trendelenburg's position.

3

Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply. 1.Bradypnea 2.Flattened neck veins 3.Decreased cardiac output 4.Hyperresonance to percussion 5.Tracheal deviation to the opposite side

3,4,5 Tension pneumothorax is the rapid accumulation of air in the pleural space. This causes extremely high intrapleural pressures, resulting in tension on the heart and great vessels. This can cause decreased cardiac output (tachycardia, hypotension), hyperresonance on percussion, and a tracheal shift away from the affected side. Bradypnea and flattened neck veins are incorrect because the client would have tachypnea and distended neck veins

A client has chronic kidney disease (CKD) that does not yet require dialysis. Which client statement indicates the need for further teaching? 1."I will reduce the sodium in my diet, and I can use salt substitutes to spice my food." 2."The amount of fluid I can have every day depends on the amount of urine I put out." 3."I will weigh myself on my bathroom scale every morning right after I have urinated." 4."I should report a gain in weight, trouble with my breathing, or increased leg swelling."

1

A client is admitted to the emergency department following a fall from a horse and the primary health care provider (PHCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? 1.Notify the PHCP before performing the catheterization. 2.Use a small-sized catheter and an anesthetic gel as a lubricant. 3.Administer parenteral pain medication before inserting the catheter. 4.Clean the meatus with soap and water before opening the catheterization kit

1

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism? 1.Dyspnea 2.Bradypnea 3.Bradycardia 4.Decreased respirations

1

A client receiving total parenteral nutrition (TPN) experiences sudden development of chest pain, dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What should the nurse suspect as a complication of the TPN? 1.Air embolism 2.Hyperglycemia 3.Catheter-related sepsis 4.Allergic reaction to the catheter

1

The nurse is providing instructions regarding the complications of peritoneal dialysis. The nurse emphasizes that onset of peritonitis, a serious complication, is most likely to be associated with which clinical manifestation? 1.Fever 2.Fatigue 3.Clear dialysate output 4.Leaking around the catheter site

1

A client diagnosed with chronic kidney disease (CKD) is scheduled to begin hemodialysis. The nurse determines that which neurological and psychosocial manifestations, if exhibited by this client, are related to the CKD? Select all that apply. 1.Agitation 2.Euphoria 3.Depression 4.Withdrawal 5.Labile emotions

1,3,4,5 The client with CKD often experiences a variety of psychosocial changes. These changes are related to uremia and to the stress associated with living with a chronic disease that is life threatening. Euphoria is not part of the clinical picture for the client in renal failure. Clients with CKD may have labile emotions or personality changes and may exhibit withdrawal, depression, or agitation which are used as coping mechanisms for a major life change. Delusions and psychosis also can occur

A client with chronic kidney disease (CKD) is being managed by continuous ambulatory peritoneal dialysis (CAPD). During outflow, the nurse notes that only half of the 2-L dialysate has returned, and the flow has stopped. Which interventions should the nurse take to enhance the outflow? Select all that apply. 1.Reposition the client. 2.Encourage a low-fiber diet. 3.Make sure the peritoneal catheter is not kinked. 4.Slide the peritoneal catheter farther into the abdomen. 5.Check that the drainage bag is lower than the client's abdomen. 6.Assess the stool history, and institute elimination measures if the client is constipated.

1,3,5,6

The nurse is working on a medical-surgical nursing unit and is caring for several clients with chronic kidney disease. The nurse interprets that which client is best suited for peritoneal dialysis as a treatment option? 1. A client with severe heart failure 2.A client with a history of ruptured diverticula 3.A client with a history of herniated lumbar disk 4.A client with a history of 3 previous abdominal surgeries

1. Peritoneal dialysis may be the treatment option of choice for clients with severe cardiovascular disease. Severe cardiac disease can be worsened by the rapid shifts in fluid, electrolytes, urea, and glucose that occur with hemodialysis. For the same reason, peritoneal dialysis may be indicated for the client with diabetes mellitus. Contraindications to peritoneal dialysis include diseases of the abdomen such as ruptured diverticula or malignancies; extensive abdominal surgeries; history of peritonitis; obesity; and a history of back problems, which could be aggravated by the fluid weight of the dialysate. Severe disease of the vascular system also may be a relative contraindication.

A client has developed acute kidney injury (AKI) as a complication of glomerulonephritis. Which should the nurse expect to observe in the client? 1.Bradycardia 2.Hypertension 3.Decreased cardiac output 4.Decreased central venous pressure

2 AKI caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of AKI commonly manifests with hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. AKI 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 any form of renal failure.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for? 1.Pneumonia 2.Pulmonary edema 3.Pulmonary embolism 4.Myocardial infarction

3

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1.Hot, flushed feeling 2.Sudden chills and fever 3.Chest pain that occurs suddenly 4.Dyspnea when deep breaths are taken

3

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1.Cyanosis 2.Hypotension 3.Paradoxical chest movement 4.Dyspnea, especially on exhalation

3

The nurse should report which assessment finding to the primary health care provider (PHCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1.Adventitious breath sounds 2.Temperature of 99.4° F (37.4° C) orally 3.Blood pressure of 198/110 mm Hg 4.Respiratory rate of 28 breaths per minute

3 Thrombolytic therapy is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore, the nurse would report the results of the blood pressure to the PHCP before initiating therapy.

The registered nurse is instructing a new nursing graduate about hemodialysis. Which statement made by the new nursing graduate indicates an understanding of the procedure for hemodialysis? Select all that apply. 1."Sterile dialysate must be used." 2."Dialysate contains metabolic waste products." 3."Heparin sodium is administered during dialysis." 4."Dialysis cleanses the blood of accumulated waste products." 5."Warming the dialysate increases the efficiency of diffusion."

3,4,5 Heparin sodium is used during dialysis, and it inhibits the tendency of blood to clot when it comes in contact with foreign substances. Option 4 is the purpose of dialysis. The dialysate is warmed to approximately 100º F to increase the efficiency of diffusion and to prevent a decrease in the client's blood temperature. Dialysate is made from clear water and chemicals and is free from any metabolic waste products or medications. Bacteria and other microorganisms are too large to pass through the membrane; therefore, the dialysate does not need to be sterile.

In performing a physical assessment of a client with chronic kidney disease (CKD), which finding should the nurse anticipate? 1.Glycosuria 2.Polyphagia 3.Crackles auscultated in the lungs 4.Blood pressure of 98/58 mm Hg

3. CKD is a condition in which the kidneys have progressive problems in clearing nitrogenous waste products and controlling fluid and electrolyte balance within the body. Cardiovascular symptoms of heart failure and hypertension are caused by the fluid volume overload resulting from the kidneys' inability to excrete water. Signs and symptoms of heart failure include jugular venous distention, S3 heart sound, pedal edema, increased weight, shortness of breath, and crackles auscultated in the lungs. The typical signs and symptoms of CKD include proteinuria or hematuria, not glycosuria. The nurse would observe anorexia and nausea in this client, not polyphagia.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action? 1.Ask a family member to stay with the client at all times. 2.Encourage the client to sleep until arterial blood gas results improve. 3.Ask the primary health care provider for a prescription for succinylcholine. 4.Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

4

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1.Initiate an intravenous line. 2.Assess the client's blood pressure. 3.Prepare to administer morphine sulfate. 4.Administer oxygen, 8 to 10 L/minute, by face mask.

4

A client undergoing hemodialysis is at risk for bleeding from the heparin used during the hemodialysis treatment. The nurse assesses for this occurrence by periodically checking the results of which laboratory test? 1.Bleeding time 2.Thrombin time 3.Prothrombin time (PT) 4.Partial thromboplastin time (PTT)

4

A client with a bladder injury has had surgical repair of the injured area with placement of a suprapubic catheter. Which is the most appropriate nursing action to prevent complications of this procedure? 1.Monitor urine output once per shift. 2.Measure specific gravity once per shift. 3.Encourage an excessive intake of oral fluids. 4.Ensure that the catheter tubing is not kinked

4

A client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. Which is the priority nursing intervention? 1.Check the shunt for the presence of bruit and thrill. 2.Observe the site once during the shift as time permits. 3.Check the results of the prothrombin time as they are determined. 4.Ensure that small clamps are attached to the arteriovenous shunt dressing.

4

A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When should the nurse plan to administer this medication? 1.During dialysis 2.Just before dialysis 3.The day after dialysis 4.On return from dialysis

4

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? 1.Warmth, redness, and pain in the left hand 2.Ecchymosis and audible bruit over the fistula 3.Edema and reddish discoloration of the left arm 4.Pallor, diminished pulse, and pain in the left hand

4

The client with a crush injury to the leg has a highly positive urine myoglobin level. The nurse should assess this client carefully for signs and symptoms of which problem? 1.Brain attack 2.Respiratory failure 3.Myocardial infarction 4.Acute tubular necrosis

4

A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse? 1.Stop the TPN solution. 2.Place the client in the high-Fowler's position. 3.Notify the primary health care provider (PHCP). 4.Place the client on the left side in the Trendelenburg's position.

4 Although stopping the TPN solution will not treat the problem, it will prevent it from worsening and is a quick action that can be completed first. Lying on the left side may prevent air from flowing into the pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. The high-Fowler's position is not helpful at this time. The PHCP should be notified, but this is not the first action

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? 1.Monitor the client. 2.Elevate the head of the bed. 3.Assess the fistula site and dressing. 4.Notify the primary health care provider (PHCP)

4 Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome, and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The PHCP must be notified. Monitoring the client, elevating the head of the bed, and assessing the fistula site are correct actions, but the priority action is to notify the PHCP.

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? 1.Excessive secretions 2.Kinks in the ventilator tubing 3.The presence of a mucous plug 4.Displacement of the endotracheal tube

4 The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would cause the high-pressure alarm to sound.

A client with chronic kidney disease has completed a hemodialysis treatment. The nurse should use which standard indicators to evaluate the client's status after dialysis? 1.Vital signs and weight 2.Potassium level and weight 3.Vital signs and blood urea nitrogen level 4.Blood urea nitrogen and creatinine levels

1

A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1.On the left side, with the head lower than the feet 2.On the left side, with the head higher than the feet 3.On the right side, with the head lower than the feet 4.On the right side, with the head higher than the feet

1

The client with chronic kidney disease has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. Which action should the nurse immediately take? 1.Change the dressing. 2.Reinforce the dressing. 3.Flush the peritoneal dialysis catheter. 4.Scrub the catheter with povidone-iodine

1

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? 1.Palpation of a thrill over the fistula 2.Presence of a radial pulse in the left wrist 3.Visualization of enlarged blood vessels at the fistula site 4.Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

1

The nurse is caring for a client with chronic kidney disease on continuous replacement renal therapy (CRRT) without the use of a hemodialysis machine. The nurse determines that which parameter is most important in ensuring success of this treatment? 1.Mean arterial pressure (MAP) 2.Systolic blood pressure (SBP) 3.Diastolic blood pressure (DBP) 4.Central venous pressure (CVP)

1

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1.Respiratory acidosis from inadequate ventilation 2.Respiratory alkalosis from anxiety and hyperventilation 3.Metabolic acidosis from calcium loss due to broken bones 4.Metabolic alkalosis from taking analgesics containing base products

1

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed? 1."I will lie on the affected side for an hour." 2."I can expect a chest x-ray exam to be done shortly." 3."I will let you know at once if I have trouble breathing." 4."I will notify you if I feel a crackling sensation in my chest."

1

A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous fistula for access. The client asks the nurse what complications can occur with the access site. What complications should the nurse inform the client about? Select all that apply. 1.Hepatitis 2.Infection 3.Hypertension 4.Muscle cramping 5.Post-treatment blood clots

1, 2 Complications directly related to the access site for hemodialysis include hepatitis or infection as a result of poor infection control practices, as well as post-treatment blood loss from certain dialysis procedure practices and the removal of needles following the procedure. In addition, heparin is often given to prevent clotting of the access site; this can potentiate postdialysis bleeding. Hypotension from rapid removal of vascular volume can occur, as can muscle cramps from fluid shifting; however, these complications are not directly related to the access site.

The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication? 1.A kink in the ventilator circuit 2.A leak in the endotracheal tube cuff 3.Displacement of the endotracheal tube 4.A disconnection of the ventilator tubing

1 A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the preset amount. Causes of high-pressure alarm activation include excess secretions; mucous plugs; the client biting on the endotracheal tube; kinks in the ventilator tubing; and the client coughing, gagging, or attempting to talk. The remaining options would trigger the low-pressure alarm.

The nurse instructs a client about continuous ambulatory peritoneal dialysis (CAPD). Which statement by the client indicates an accurate understanding of CAPD? 1."No machinery is involved, and I can pursue my usual activities." 2."A cycling machine is used, so the risk for infection is minimized." 3."The drainage system can be used once during the day and a cycling machine for 3 cycles at night." 4."A portable hemodialysis machine is used so that I will be able to ambulate during the treatment."

1 CAPD closely approximates normal renal function, and the client will need to infuse and drain the dialysis solution several times a day. No machinery is used, and CAPD is a manual procedure.

A primary health care provider (PHCP) writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made? 1."The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." 2."A T-piece will be attached to the ventilator and provide supplemental oxygen at a concentration that is 10% higher than the ventilator setting." 3."It will provide pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts." 4."It involves removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time."

1 IMV/SIMV is 1 of the methods used for weaning. With this method, the respiratory rate is gradually decreased until the client assumes all of the work of breathing on his or her own. This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation. Therefore, the remaining options are incorrect.

A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? 1.Remove the dressing. 2.Reinforce the dressing. 3.Call the primary health care provider (PHCP). 4.Measure oxygen saturation by oximetry.

1 Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occur, the nurse should remove the dressing immediately, allowing air to escape. Therefore, reinforcing the dressing is an incorrect action. The nurse would measure oxygen saturation by oximetry and would call the PHCP, but these would not be the first actions in this situation.

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location? 1.Just under the left clavicle 2.Midsternum, 1 inch to the left 3.Over the fifth intercostal space 4.Midsternum, 1 inch to the right

1 The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place the stethoscope just under the left clavicle. All of the other options are incorrect locations for assessing the left apex.

The nurse is assessing the renal function of a client at risk for acute kidney injury. After noting the amount of urine output and urine characteristics, the nurse proceeds to assess which as the best indirect indicator of renal status? 1.Blood pressure 2.Apical heart rate 3.Jugular vein distention 4.Level of consciousness

1 The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. For kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. The heart rate affects the cardiac output but can be altered by factors unrelated to kidney function. Jugular vein distention and level of consciousness are unrelated items.

The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1.Water or a kink in the tubing 2.Biting on the endotracheal tube 3.Increased secretions in the airway 4.Disconnection or leak in the system 5.The client ceasing spontaneous breathing

1,2,3 Causes of high-pressure ventilator alarms include water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator. A disconnection or leak in the system and the client ceasing to spontaneously breathe are causes of a low-pressure ventilator alarm.

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. 1.Check the level of the drainage bag. 2.Reposition the client to his or her side. 3.Place the client in good body alignment. 4.Check the peritoneal dialysis system for kinks. 5.Contact the primary health care provider (PHCP). 6.Increase the flow rate of the peritoneal dialysis solution.

1,2,3,4

A client is about to begin hemodialysis. Which measures should the nurse employ in the care of the client? Select all that apply. 1.Using sterile technique for needle insertion 2.Using standard precautions in the care of the client 3.Giving the client a mask to wear during connection to the machine 4.Wearing full protective clothing such as goggles, mask, gloves, and apron 5.Covering the connection site with a bath blanket to enhance extremity warmth

1,2,3,4 Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both nurse and client are extremely important. It also is imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and apron. The connection site should not be covered; it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the hemodialysis procedure.

A client with end-stage renal disease (ESRD) has the problem of ineffective coping. Which nursing interventions are appropriate in working with this client? Select all that apply. 1.Acknowledge the client's feelings. 2.Assess the client and family's coping patterns. 3.Explore the meaning of the illness with the client. 4.Set limits on mood swings and expressions of hostility. 5.Give the client information when the client is ready to listen.

1,2,3,5

The nurse is performing assessment on a client with acute kidney injury who is in the oliguric phase. Which should the nurse expect to note? Select all that apply. 1.Increased serum creatinine level 2.A low and fixed specific gravity 3.Increased blood urea nitrogen (BUN) level 4.A urine output of 600 to 800 mL in a 24-hour period 5.Urine osmolarity of approximately 300 mOsm/kg (300 mmol/kg)

1,2,3,5

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The primary health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply. 1.Administer oxygen. 2.Assess the blood pressure. 3.Start an intravenous (IV) line. 4.Prepare to administer warfarin sodium. 5.Prepare to administer morphine sulfate. 6.Place the client on bed rest in a supine position.

1,2,3,5 If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bed rest, with the head of the bed elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain and apprehension. An IV line also will be required, and vital signs must be monitored. Heparin therapy (not warfarin sodium) is administered

A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply. 1.Administer oxygen to the client. 2.Continue dialysis at a slower rate after checking the lines for air. 3.Notify the primary health care provider (PHCP) and Rapid Response Team. 4.Stop dialysis, and turn the client on the left side with head lower than feet. 5.Bolus the client with 500 mL of normal saline to break up the air embolus.

1,3,4 If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, position the client so the air embolus is in the right side of the heart, notify the PHCP and Rapid Response Team, and administer oxygen as needed. Slowing the dialysis treatment or giving an intravenous bolus will not correct the air embolism or prevent complications.

A client who is performing peritoneal dialysis at home calls the clinic and reports that the outflow from the dialysis catheter seems to be decreasing in amount. The clinic nurse should ask which question first? 1."Have you had any diarrhea?" 2."Have you been constipated recently?" 3."Have you had any abdominal discomfort?" 4."Have you had an increased amount of flatulence?"

2

A client with glomerulonephritis has developed acute kidney injury (AKI) as a complication. The nurse should expect to note which abnormal finding documented on the client's medical record? 1.Bradycardia 2.Hypertension 3.Decreased cardiac output 4.Decreased central venous pressure

2

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1.A low respiratory rate 2.Diminished breath sounds 3.The presence of a barrel chest 4.A sucking sound at the site of injury

2

The nursing student is assigned to care for a client with a diagnosis of acute kidney injury (AKI), diuretic phase. The nursing instructor asks the student about the primary goal of the treatment plan for this client. Which goal, if stated by the nursing student, indicates an adequate understanding of the treatment plan for this client? 1.Prevent fluid overload. 2.Prevent loss of electrolytes. 3.Promote the excretion of wastes. 4.Reduce the urine specific gravity.

2 In the diuretic phase, fluids and electrolytes are lost in the urine. As a result, the plan of care focuses on fluid and electrolyte replacement and monitoring. Options 1, 3, and 4 are not the primary concerns in this phase of AKI.

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium. The client's prothrombin time is 20 seconds, with a control of 11 seconds. How should the nurse interpret these results? 1.The client needs to have the test repeated. 2.Client results are within the therapeutic range. 3.Client results are higher than the therapeutic range. 4.Client results are lower than the needed therapeutic level.

2 The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds; therefore, the result is within the therapeutic range

What early signs and symptoms should the nurse assess for in a client with a suspected pulmonary embolism? Select all that apply. 1.Orthopnea 2.Tachypnea 3.Restlessness 4.Normal oxygen saturation 5.Feeling of impending doom

2,3,5 Signs and symptoms of a pulmonary embolism include the sudden onset of dyspnea, apprehension and restlessness, a feeling of impending doom, cough, hemoptysis, tachypnea, crackles, petechiae over the chest and axillae, and a decreased arterial oxygen saturation. If suspected, the nurse immediately notifies the Rapid Response Team and primary health care provider. The nurse stays with the client, reassures the client, and elevates the head of the bed. The nurse prepares to administer oxygen and obtains the vital signs and checks lung sounds. The nurse continues to monitor the client closely, prepares the client for tests prescribed to confirm the diagnosis, and prepares to obtain an arterial blood gas. When prescribed, the client is prepared for the administration of heparin therapy or other therapies such as embolectomy or placement of a vena cava filter if necessary. Finally, the nurse documents the event, the interventions taken, and the client's response to treatment.

The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply. 1.Pressure support is added to the oxygen system. 2.The T-piece is connected to the client's artificial airway. 3.The client is removed from the mechanical ventilator for a short period of time. 4.The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on his or her own. 5.Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting.

2,3,5 The T-piece (or Briggs device) requires that the client be removed from the mechanical ventilation for short periods of time, usually beginning with a 5-minute period. The ventilator is disconnected, and the T-piece is connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at a FiO2 that is 10% higher than the ventilator setting. Option 4 describes intermittent mandatory ventilation/synchronized intermittent mandatory ventilation. Pressure support may be prescribed to open alveoli in some clients while on mechanical ventilation.

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1.Hypovolemia 2.Acute kidney injury 3.Glomerulonephritis 4.Urinary tract infection

2. The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine, male, 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.

A client is being evaluated as a potential kidney donor for a family member. The client asks the nurse why separate teams are evaluating the donor and recipient. What is the most appropriate response by the nurse? 1.Helps reduce the cost of the preoperative workup 2.Saves the client and the recipient valuable preoperative time 3.Avoids a conflict of interest between the team evaluating the recipient and the team evaluating the donor 4.Provides for a sufficient number of persons reviewing the case so that no information is overlooked

3

A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary? 1.Encourage intake of fluids. 2.Shave the anticipated entry site. 3.Ask the client about allergies and previous reactions. 4.Contact the operating room regarding the need for the procedure

3

The nurse is reviewing the list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse should base the response on knowing that which is the action of the glucose in the solution? 1.Decreases the risk of peritonitis 2.Prevents disequilibrium syndrome 3.Increases osmotic pressure to produce ultrafiltration 4.Prevents excess glucose from being removed from the client

3

The primary health care provider writes prescriptions for a client with chronic kidney disease (CKD). Which prescription should the nurse question? 1.Insert a saline lock. 2.Obtain a daily weight. 3.Provide a high-protein diet. 4.Administer a calcium supplement with each meal.

3

A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the following day. The client says to the nurse, "I'll be so happy when the fistula is made tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which interpretation should the nurse make based on the client's statement? 1.The client has an accurate understanding of the procedure and aftercare. 2.The client does not realize how painful removal of the dialysis catheter will be. 3.The client does not understand that the site needs to mature or develop for 1 to 2 weeks before use. 4.The client is not aware that the alternative access site is left in place prophylactically for 2 months.

3 An AV fistula is the internal creation of an arterial-to-venous anastomosis. This causes engorgement of the vein, allowing both the artery and the vein to be easily cannulated for hemodialysis. Fistulas take 1 to 2 weeks to mature (engorgement) or develop before they can be used for dialysis, so the current method of access must remain in place to be used during that period. Options 1, 2, and 4 are incorrect interpretations of the client's statement.

A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? 1.Pyelonephritis 2.Glomerulonephritis 3.Trauma to the bladder or abdomen 4.Renal cancer in the client's family

3 Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client described in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather, the pain would be in the flank area.

A client who is undergoing peritoneal dialysis calls the nurse at the renal unit and reports the presence of severe abdominal pain and diarrhea. The client also informs the nurse that the peritoneal dialysis returns are brown-tinged in color. Which would the nurse suspect? 1.Infection 2.An intact catheter 3.Bowel perforation 4.Bladder perforation

3 Complications of a peritoneal catheter include infection, perforation of the bowel or bladder, and bleeding. Brown-tinged returns suggest bowel perforation, which usually is accompanied by severe abdominal pain and diarrhea. Cloudy or opaque returns suggest possible infection. Urine-colored returns suggest possible bladder perforation. An intact catheter is unrelated to the information provided in the question

The nurse checks the serum myoglobin level for a client with a crush injury to the right lower leg because the client is at risk for developing which type of acute kidney injury? 1.Prerenal 2.Postrenal 3.Intrarenal 4.Extrarenal

3 Serum myoglobin levels increase in crush injuries when large amounts of myoglobin and hemoglobin are released from damaged muscle and blood cells. The accumulation may cause acute tubular necrosis, an intrarenal cause of renal failure. Prerenal causes are conditions that interfere with the perfusion of blood to the kidney. Postrenal causes include conditions that cause urinary obstruction distal to the kidney. The cause and the type of renal failure may determine the interventions used in treatment.

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing? 1.Fat embolism 2.Mediastinal shift 3.Mediastinal flutter 4.Hypovolemic shock

3 The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client's CVP rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter. The client with fat embolism experiences chest pain and dyspnea, but this condition occurs as a complication of a bone fracture. Mediastinal shift is a condition in which the structures of the mediastinum shift or move to the opposite side of the chest cavity; this may be caused by a pleural effusion or tension pneumothorax. In hypovolemic shock, the blood pressure falls and the pulse rises; this occurs following hemorrhage

The nurse instructor is evaluating a nursing student for knowledge regarding care of a client with acute kidney injury. Which statement by the student demonstrates the need for further teaching about the diuretic phase of acute kidney injury? 1."The increase in urine output indicates the return of some renal function." 2."The diuretic phase develops about 14 days after the initial insult and lasts about 10 days." 3."The diuretic phase is characterized by an increase in urine output of about 500 mL in a 24-hour period." 4."The blood urea nitrogen and creatinine levels will continue to rise during the first few days of diuresis."

3 The diuretic phase of acute kidney injury is characterized by an increase in urine output of more than 1000 mL in a 24-hour period. This increase in urine output indicates the return of some renal function; however, blood urea nitrogen and creatinine levels continue to rise during the first few days of diuresis. The diuretic phase develops about 14 days after the initial insult and lasts about 10 days.

The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1.A disconnection of the ventilator tubing 2.An exaggerated client inspiratory effort 3.Accumulation of respiratory secretions 4.Generation of extreme negative pressure by the client

3 The high-pressure alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set tidal volume. Causes include tubing obstruction or kinks, breathing "out of phase" or "bucking the ventilator," accumulation of secretions, condensation of water in the ventilator tubing, coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary compliance, and pneumothorax. The remaining options identify causes for triggering the low-pressure alarm.

The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1.Excessive bubbling in the water seal chamber 2.Vigorous bubbling in the suction control chamber 3.Drainage system maintained below the client's chest 4.50 mL of drainage in the drainage collection chamber 5.Occlusive dressing in place over the chest tube insertion site 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3,4,5,6 The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re-expanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL/hr is considered excessive and requires notification of the surgeon. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse measures the cardiac output of a client and finds it to be 6 L/min. Which amount of kidney perfusion should the nurse anticipate? 1.100 to 300 mL/min 2.500 to 1000 mL/min 3.1200 to 1500 mL/min 4.2000 to 2500 mL/min

3. The kidneys normally receive about 20% to 25% of the cardiac output when the client is at rest. If the cardiac output is 6 L/min, the kidneys receive 1.2 to 1.5 L/min, which is equal to 1200 to 1500 mL/min

A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action should the nurse take to eliminate the problem? 1.Silence the alarm to avoid disturbing the client. 2.Check the ventilator circuit for any disconnections. 3.Inflate the cuff of the endotracheal tube to a pressure of 25 mm Hg. 4.Empty excess accumulated water from the ventilatory circuit tubing

4

A client undergoing hemodialysis begins to experience muscle cramping. What is the best action by the hemodialysis nurse in this situation? 1.Administer hypotonic saline. 2.Administer magnesium sulfate. 3.Increase the ultrafiltration rate. 4.Decrease the ultrafiltration rate

4

A week after kidney transplantation, a client develops a temperature of 101° F (38.3° C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? 1.Antibiotic therapy 2.Peritoneal dialysis 3.Removal of the transplanted kidney 4.Increased immunosuppression therapy

4

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1.Bilateral wheezing 2.Inspiratory crackles 3.Intercostal retractions 4.Increased respiratory rate

4

To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what should the nurse do first? 1.Request a cardiopulmonary consult. 2.Teach the client to splint the incision. 3.Teach the proper technique for huff coughing. 4.Ensure that the client is experiencing adequate pain control

4 Coughing is 1 of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways and prevent atelectasis. The client with an abdominal incision is hesitant to cough unless pain control is adequate. The incision in an open cholecystectomy is just under the diaphragm in the right upper quadrant of the abdomen, making coughing and deep breathing painful. The nurse should first ensure that pain control is adequate so that pulmonary hygiene measures are maximally effective. A cardiopulmonary consult is requested for clients with preexisting risk caused by lung pathology or for clients already experiencing postoperative respiratory complications. Splinting the incision is an effective postoperative strategy for assisting with effective coughing and deep breathing, but it should follow pain control. Huff coughing, although it can be used in the postoperative client, is an effective coughing strategy that is most often recommended for clients with chronic obstructive airway disorders.

The spouse of a client with acute kidney injury secondary to heart failure asks the nurse how a heart problem can affect the kidneys. The nurse should formulate a response using what fact about the kidneys? 1.The kidneys get fatigued from having to filter too much fluid. 2.The kidneys can react adversely to moderate doses of furosemide. 3.The kidneys will shut down easily if serum levels of digoxin are high. 4.The kidneys generally require and receive about 20% to 25% of the resting cardiac output.

4 Heart failure is referred to as a prerenal cause of acute kidney injury because heart failure results in decreased blood flow to the kidneys. The kidneys normally receive about 20% to 25% of the cardiac output and require adequate perfusion to function properly. With a significant or prolonged decrease in blood supply, the kidneys can fail. Options 1 and 3 are incorrect. As for option 2, large doses of furosemide resulting in severe dehydration may lead to decreased kidney perfusion, but moderate doses of furosemide do not cause prerenal acute kidney injury, and furosemide may be used to treat acute kidney injury.

The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm? 1.Shut the alarm off and call for help. 2.Call the respiratory therapy department to fix the problem. 3.Call the primary health care provider (PHCP) for further instructions. 4.Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.

4 If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a mechanical ventilator, the nurse should manually ventilate the client with a resuscitation device. The nurse should never shut off the alarm. It is not necessary to contact the PHCP, although the respiratory therapist may be notified to assist in troubleshooting the cause of the problem. However, the initial nursing action would be to manually ventilate the client.