Exam 5

A client has a glomerular filtration rate (GFR) of 43mL/min/1.73m2. Based on this GFR, the nurse interprets that the clients chronic kidney disease is at what level?

Stage 3

After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition?

"I will increase my intake of protein."

The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer?

"The sudden increase in blood pressure can rupture a cerebral blood vessel."

The nurse is caring for a patient who had spinal cord injury and with a halo vest. To provide comfort measures for this patient, which nursing interventions are included in the plan of care? Select all that apply.

-Clean the pin sites of the halo device daily. -A torque screwdriver should be readily available in case the screws on the frame need tightening. - Inspect skin under the halo vest for perspiration, redness and blistering. -Keep liner of the halo vest dry to prevent skin excoriation.

The nurse is caring for a patient in a persistent vegetative state. The nurse is regularly monitoring for potential complications. The nurse should assess which complications related to immobility and decreased level of consciousness. Select all that apply.

-Contractures -Pressure ulcers -Venous thromboembolism -Pneumonia

The nurse is assessing a patient with myasthenia gravis. Which are the characteristics of this disease? Select all that apply.

-DIplopia and ptosis -Dysphonia and dysphagia -Weakness of intercostal muscles

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.)

-Patient with benign prostatic hypertrophy - Patient with ureterolithiasis and ureteral strictures

A patient with myasthenia gravis is prescribed pyridostigmine bromide (Mestinon). When teaching about this medication, what should the nurse teach the patient to immediately report? Select all that apply.

-abdominal cramps -diarrhea -excessive salivation

The rehabilitation nurse caring for a the patient with Lumbar (L1) complete spinal cord injury (SCI) is developing the nursing care plan. Which intervention is most appropriate should the nurse implement?

Administer low-dose subcutaneous anticoagulants

The nurse is caring for a client postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms or rejection what assessment should the nurse prioritize?

Assessment of the quantity and quality of the client's urine output

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

Flaccid extremities

A patient with abnormally high serum creatinine level had a renal biopsy procedure done. What is the most appropriate nursing action post procedure?

Monitor hematocrit level.

The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What would be an appropriate intervention for this diagnosis?

Monitor serum electrolytes and osmolality.

The nurse is taking the vital signs of a client after hemodialysis. The patient states feeling tired with blood pressure of 110/58 mm Hg, pulse 66 beats/min, oxygen saturation of 95% on room air and temperature is 99.8° F (37.6° C). What is the most appropriate action by the nurse?

Monitor the client's temperature.

The nurse is performing an admission history. The 76-year-old client is being treated with carbidopa/ levodopa (Sinemet) for Parkinson's disease within the last 5 years. Which information is most important for the nurse to report to the health care provider?

Rhythmic jerking movements of the hands

The patient with myasthenia gravis exhibit signs of weak cough. The nurse noted the patient had an episode of frequent cough and was choking on food during a meal. What is the next best action of the nurse?

keep patient nothing by mouth and report to health care provider

The nurse recognizes that a patient with a spinal cord injury (SCI) is at risk for muscle spasticity. Which management of care can the nurse best prevent this complication of a SCI?

perform passive range of motion exercises as ordered

A patient obtained an acceleration-deceleration injury in a motor vehicle collision. The patient developed signs of cerebral edema and poor cerebral perfusion with a GCS of 8. While in the intensive care unit, what would the nurse anticipate as part of the collaborative care for this patient? Select all that apply

-Administer osmotic diuretics intravenously -Ensure aseptic technique when handling the intraventricular catheter. -Reduce cellular metabolic demand using sedatives such as propofol (Diprivan)

A patient is scheduled to have an arteriovenous (AV) graft surgically placed for hemodialysis. What should the nurse include when teaching the patient about this fistula? Select all that apply

-Avoid using the arm with the graft for blood pressure readings -A functioning graft has a palpable pulse and audible bruit. -The vascular access device should not be used for any purpose other than dialysis

A patient diagnosed with multiple sclerosis (MS) is admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication?

-Decreased muscle spasms in the affected extremities

The nurse is caring for a patient with end-stage kidney disease admitted to the hospital with fluid overload, electrolyte imbalances and uremia. The patient has been on hemodialysis for three years now. Past medical history reveals diabetes mellitus, diabetic nephropathy, and hypertension. While reviewing the chart, which of the following medications will the nurse anticipate to be included in the collaborative care of this patient? Select all that apply

-Epoetin alfa (EPOGEN) 100 units /kg subcutaneous every 3 days - Sevelamer hydrochloride (Renagel) 800 mg by mouth with meals -Furosemide (Lasix) 20 mg intravenously (IV) push every 8 hours -Novolog (insulin aspart) subcut per sliding scale AC (before meals) &HS (at bedtime) - Lantus (insulin glargine) 30 units subcut daily -Folic Acid 1 mg by mouth daily

Following a fall, a patient is brought to the emergency department. The patient had a brief loss of consciousness. The patient complains of headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area, and is currently having a seizure. What should the nurse anticipate regarding the care of this patient?

-This is an emergency situation that is likely due to an epidural hematoma and requires surgery

The nurse is caring for a client with Guillain-Barré syndrome. Which collaborative care should the nurse expect to provide to this client? Select all that apply

-administration of intravenous immunoglobulin -cardiac monitoring to detect dysrhythmias and intravenous fluids if hypotensive -emergent ventilatory support during acute phase as needed -therapeutic plasma exchange

The nurse suspects that a client with a spinal cord injury is experiencing autonomic dysreflexia. Which findings will help the nurse determine the cause that may trigger this condition? Select all that apply.

-distended bladder -skin pressure ulcer on the leg -constipation

During an assessment, the nurse becomes concerned that a patient is demonstrating typical manifestations of amyotrophic lateral sclerosis. What findings did the nurse use to make this clinical determination? Select all that apply

-fasciculations of the muscles -limb weakness -spasticity -fatigue

A school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, what should the nurse do next?

-immobilize the neck, securing the head

A client with a cervical spinal cord injury (SCI) is admitted to the neuro intensive care unit. Which actions should the nurse include during the acute care for this client? Select all that apply.

-insertion of indwelling catheter -monitoring of the heart rate -immobilization of the vertebral column -Autonomic dysreflexia prevention

The nurse is assessing a patient with Guillain-Barré syndrome. What should the nurse expect to assess in this patient? Select all that apply

-muscular weakness begins in the legs and progress upward -paresthesias of hands and feet -decreased deep tendon reflexes

The nurse recognizes that a paitent with a spinal cord injury (SCI) is at risk for muscle spacity. Which management of care can the nurse best prevent this complication of SCI?

-performing passive range of motion exercises as ordered

The nurse notes that a patient with multiple sclerosis is experiencing ataxia. Which medication should the nurse expect to be prescribed for this clinical manifestation?

-propranolol (Inderal)

Which nursing action can be implemented to prevent acute kidney injury? Select all that apply

-treat hypotension promptly -continued monitoring of urine output -provide meticulous care to patients with indwelling catheter -closely monitor dosage and blood levels of nephrotoxic drugs

A patient is scheduled for a computed tomography (CT) scan of the abdomen with contrast. The patient has a baseline serum creatinine of 2.1 mg/dL. In preparing this patient for the procedure, the nurse anticipates which order?

Administer preprocedure hydration with saline and N-acetylcysteine as prescribed

The nurse just received an urgent laboratory values on a patient with renal failure. The potassium is 6.3 mEq/L. The telemetry monitor is showing peaked T waves. Which prescription from the primary health care provider should be implemented first?

Administer regular insulin intravenously (IV)

Paramedics have brought an intubated patient to the emergency department following a head injury due to acceleration-deceleration motor vehicle accident. Patient is showing signs of agitation. Increased intracranial pressure (ICP) is suspected. Which of the following is most appropriate action the nurse would include in the plan of care at this time?

Administer benzodiazepines as prescribed.

The nurse is caring for a patient who is rapidly progressing toward brain death. Which of the following clinical signs obtained by the nurse best describes state of brain death?

Apnea, coma, and absence of brain stem reflexes

A patient with head trauma is exhibiting assessment as follows: Temperature 101.2 F (38.4 C), blood pressure 125/64, pulse rate 70/min, respirations 20/min. Which set of subsequent vital signs indicates cushing's triad?

Blood pressure: 170/55, pulse: 52, respirations: 8

A nurse is caring for a critically ill patient with autonomic dysreflexia. What manifestations should the nurse expect in this client?

Bradycardia and hypertension

The nurse is caring for a patient with a traumatic brain injury in the neuro ICU. Which of the following assessment would most likely suggest that the patient may be experiencing unfavorable increased brain compression, possible midline shift and causing possible irreversible brain damage?

Cerebral perfusion pressure of 48 mmhg

A intensive care unit nurse is receiving change of shift report about the client who had a myocardial infarction. The client's labs reveal a serum potassium level of 5.9 mg/dL, a serum creatinine level of 2.5 mg/dL, and a urine output of 500 mL/day. What is the priority plan of action by the nurse?

Check the cardiac status with a heart monitor

After change-of-shift report, which client should the nurse assess first?

Client with myasthenia gravis who is reporting increased muscle weakness and dysphagia

A septic shock patient with acute kidney injury is admitted in the intensive care unit. The patient is hemodynamically unstable, but renal replacement therapy is needed to manage hypervolemia and hyperkalemia. Which renal replacement therapy is indicated for this patient?

Continuous venovenous hemofiltration (CVVH)

What should the nurse suspect when hourly assessment on a patient post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?

Diabetes insipidus with decreased urine specific gravity

A client is having a peritoneal dialysis treatment. The nurse notes an cloudy color to the effluent. What is the priority collaborative care the nurse anticipates at this time?

Drainage fluid is examined, sent to laboratory for cell count, gram stain and culture.

A patient has been admitted to the intensive care unit after developing acute kidney injury (AKI). The nurse noted a decline in glomerular filtration rate and oliguria upon assessment. The nurse should anticipate performing interventions to resolve which of the following health problems related to the AKI?

Hyperkalemia and metabolic acidosis

A nurse is caring for a patient who is the diuresis phase of AKI. The nurse should closely monitor for what complication during this phase?

Hyperphosphatemia

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression, increased ICP and causing possible brain stem damage?

Hyperthermia

The nurse is caring for a patient with a head injury with cerebral edema and increased intracranial pressure (ICP). To prevent further transient increases of intracranial pressure from occurring, the nurse should implement what intervention?

Implement measures to prevent valsalva maneuver such as stool softener.

A nurse is planning the care of a 28-year old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client?

In the morning with frequent rest periods

During hemodialysis, the patient reports nausea, headache, and chest pain to the nurse. The patient has a blood pressure of 80/48 mm Hg. Which nursing action would be most beneficial?

Infusing normal saline solution as ordered.

A patient with spinal cord injury has a nursing diagnosis of impaired mobility. The nurse recognizes the increased risk of developing deep vein thrombosis (DVT). Which of the following would be included most appropriate nursing intervention to prevent a DVT from occurring?

Initiating anticoagulation within 72 hours of injury as ordered

A patient with a recent diagnosis of end-stage kidney disease (ESKD) is scheduled to soon begin hemodialysis. A nephrology nurse has been conducting extensive patient teaching in anticipation of this treatment. What diet should the nurse recommend to minimize patient's risk of complications and interdialytic weight gain?

Low-protein, low-sodium diet

The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client's recent history?

Myocardial infarction/ chest pain

The nurse is caring for a patient in the intensive care unit (ICU) who has a traumatic brain injury and is exhibiting an altered level of consciousness. Monitoring reveals that the patient's mean arterial pressure (MAP) is 65 mm Hg with an intracranial pressure (ICP) reading of 20 mm Hg. What is the nurse's most appropriate action?

Notify health care provider and anticipate possible craniotomy for blood clot evacuation.

The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding?

Patient with Kussmaul respirations

The emergency room nurse is caring for a patient who has been brought in by ambulance after substantial blunt force trauma from a fall at home. What clinical sign is highly predictive of a basilar skull fracture?

Periorbital ecchymosis

The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address which characteristic of this health problem?

Protienuria

A client is recovering from a kidney transplant. The client's urine output was 1500 mL over the last 12- hour period since transplantation. What is the priority assessment by the nurse?

Taking blood pressure

A nurse working in the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When developing the plan of care, what aspect of the patient's neurologic and functional status should the nurse consider?

The patient will require full assistance for all aspects of bowel and bladder elimination.

The nurse is developing a plan of care for a patient who is receiving treatment of Guillain-Barré syndrome (GBS). What nursing intervention would receive priority for this patient?

Using the incentive spirometer as prescribed