med surg 2 exam 2
A gerontologic nurse is assessing a patient who has numerous comorbid health problems. What assessment findings should prompt the nurse to suspect a UTI? Select all that apply. A) Food cravings B) Upper abdominal pain C) Insatiable thirst D) Uncharacteristic fatigue E) New onset of confusion
d
An adult patient has been hospitalized with pyelonephritis. The nurses review of the patients intake and output records reveals that the patient has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding? A) Supplement the patients fluid intake with a high-calorie diet. B) Emphasize the need to limit intake to 2 L of fluid daily. C) Obtain an order for a high-sodium diet to prevent dilutional hyponatremia. D) Encourage the patient to continue this pattern of fluid intake.
d
What should be included in the patients care plan when establishing an exercise program for a patient affected by a stroke? A) Schedule passive range of motion every other day. B) Keep activity limited, as the patient may be over stimulated. C) Have the patient perform active range-of-motion (ROM) exercises once a day. D) Exercise the affected extremities passively four or five times a day
d
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: dysfunction in the cerebrum. risk for increased intracranial pressure. dysfunction in the brain stem. dysfunction in the spinal column.
dysfunction in the brain stem.
Which is the most common motor dysfunction seen in clients diagnosed with stroke? Ataxia Diplopia Hemiplegia Hemiparesis
hemiplegia
A decrease in circulating white blood cells is granulocytopenia. thrombocytopenia. leukopenia. neutropenia.
leukopenia
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects: squamous cell carcinoma. actinic keratoses. melanoma. basal cell carcinoma.
melanoma
After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? Giving him a barbiturate Placing him on mechanical ventilation Performing a lumbar puncture Elevating the head of his bed
perform a lumbar puncture
Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? P wave QRS complex PR interval QT interval
qrs complex
A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to: control headache pain. enhance the immune response. prevent intracranial bleeding. reduce the chance of blood clot formation.
reduce the chance of blood clot formation.
Which of the following is the most sensitive indicator of renal function? Serum creatinine Blood urea nitrogen (BUN) Creatinine clearance Potassium
serum creatinine
When the nurse observes that the client's heart rate increases during inspiration and decreases during expiration, the nurse reports that the client is demonstrating normal sinus rhythm. sinus bradycardia. sinus dysrhythmia. sinus tachycardia.
sinus dysrythmia
An oncology nurse is caring for a client who is taking antineoplastic agents. What symptoms would the nurse consider with tumor lysis syndrome when monitoring this client? symptoms of gout symptoms of hypertension symptoms of constipation symptoms of anemia
symptoms of gout
The brain stem holds the medulla oblongata. What is the function of the medulla oblongata? transmits sensory impulses from the brain to the spinal cord controls striated muscle activity in blood vessel walls controls parasympathetic nerve impulses in the pons transmits motor impulses from the brain to the spinal cord
transmits motor impulses from the brain to the spinal cord
The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time? 1 hour 3 to 6 hours 12 hours 24 to 36 hours
1 hr
The cerebral circulation receives approximately what percentage of the cardiac output? 15% 10% 25% 20%
15%
What is the drug of choice for a stable client with ventricular tachycardia? Atropine Amiodarone Procainamide Lidocaine
Amiodarone
A patient has had several episodes of recurrent tachydysrhythmias over the last 5 months and medication therapy has not been effective. What procedure should the nurse prepare the patient for? Insertion of an ICD Insertion of a permanent pacemaker Catheter ablation therapy Maze procedure
Catheter ablation therapy
The nurse is caring for a client who is interested in learning about hospice care. Which of the eligibility criteria would the nurse stress? Serious, progressive illness Choice of palliative care over cure focused Limited life expectancy Physician-certified illness
Choice of palliative care over cure focused
A patient had a lumbar puncture 3 days ago in the outpatient clinic and calls the nurse with complaints of a throbbing headache. What can the nurse educate the patient to do for relief of the discomfort? Select all that apply. Limit the amount of fluid to decrease cerebral edema. Force fluids (unless contraindicated). Get plenty of bed rest. Take some over-the-counter analgesics. Walk around.
Get plenty of bed rest. Take some over-the-counter analgesics. Force fluids (unless contraindicated).
Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. Intracranial hemorrhage Ischemic stroke Age 18 years or older Systolic BP less than or equal to 185 mm Hg Major abdominal surgery within 10 days
Intracranial hemorrhage Major abdominal surgery within 10 days
A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia? Calcium and magnesium Potassium and calcium Magnesium and potassium Potassium and sodium
Magnesium and potassium
Which of the following is the nurse's primary concern when providing end-of-life care for a client and the family? Select all that apply. Maintaining client comfort Arranging plans for after death Supporting family members Providing personal care Completing a head-to-toe assessment Encouraging fluids
Maintaining client comfort Supporting family members Providing personal care
The nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II as well as a bizarre, abnormal shape to the QRS complex. The nurse has likely observed which ventricular dysrhythmia? Ventricular bigeminy Ventricular tachycardia Premature ventricular contraction Ventricular fibrillation
Premature ventricular contraction * A premature ventricular contraction (PVC) is an impulse that starts in a ventricle before the next normal sinus impulse. Ventricular bigeminy is a rhythm in which every other complex is a PVC. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute. Ventricular fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles.
A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? Anticipate the client will exhibit some degree of expressive or receptive aphasia. Place the wheelchair on the client's left side when transferring him into a wheelchair. Provide close supervision because of the client's impulsiveness and poor judgment. Support the right arm with a sling or pillow to prevent subluxation.
Provide close supervision because of the client's impulsiveness and poor judgment.
The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess for which conditions? Select all that apply. Sloughing tissue Tissue necrosis Active bleeding Effectiveness of the antidote
Sloughing tissue Effectiveness of the antidote Tissue necrosis
A client with heart failure asks the nurse how dobutamine affects the body's circulation. What is the nurse's best response? The medication increases the force of the myocardial contraction. The medication causes the kidneys to retain fluid and increase intravascular volume. The medication increases the heart rate. The medication helps the kidneys produce more urine.
The medication increases the force of the myocardial contraction.
A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education? When symptoms cease, the client will return to presymptomatic state. A TIA is an insidious, often chronic episode of neurologic impairment. Symptoms of a TIA may linger for up to a week. Two thirds of people that experience a TIA will go on to develop a stroke.
When symptoms cease, the client will return to presymptomatic state.
A female patient has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the patient, the nurse should address what topic? A) The risk of developing a vaginal yeast infection as a consequent of antibiotic therapy B) The need to expect a heavy menstrual period following the course of antibiotics C) The risk of developing antibiotic resistance after the course of antibiotics D) The need to undergo a series of three urine cultures after the antibiotics have been completed
a
The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize? A) Assessment of the quantity of the patients urine output B) Assessment of the patients incision C) Assessment of the patients abdominal girth D) Assessment for flank or abdominal pain
a
The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response? A) Inform the care team and assess for further signs of possible increased ICP. B) Administer bronchodilators as ordered and monitor the patients LOC. C) Increase the patients bed height and reassess in 30 minutes. D) Administer a bolus of normal saline as ordered.
a
The nurse on a urology unit is working with a patient who has been diagnosed with oxalate renal calculi. When planning this patients health education, what nutritional guidelines should the nurse provide? A) Restrict protein intake as ordered. B) Increase intake of potassium-rich foods. C) Follow a low-calcium diet. D) Encourage intake of food containing oxalates.
a
When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A) Frustration around changes in function and communication B) Unmet physiologic needs C) Changes in brain activity during sleep and wakefulness D) Temporary changes in metabolism
a
The nurse is preparing to collect an ordered urine sample for urinalysis. The nurse should be aware that this test will include what assessment parameters? Select all that apply. A) Specific gravity of the patients urine B) Testing for the presence of glucose in the patients urine C) Microscopic examination of urine sediment for RBCs D) Microscopic examination of urine sediment for casts E) Testing for BUN and creatinine in the patients urine
abcd
You are caring for an adult patient who has developed a mild oral yeast infection following chemotherapy. What actions should you encourage the patient to perform? Select all that apply. A) Use a lip lubricant. B) Scrub the tongue with a firm-bristled toothbrush. C) Use dental floss every 24 hours. D) Rinse the mouth with normal saline. E) Eat spicy food to aid in eradicating the yeast
acd
The patient has been diagnosed with urge incontinence. What classification of medication does the nurse expect the patient will be placed on to help alleviate the symptoms? Antispasmodic agents Urinary analgesics Antibiotics Anticholinergic agents
anticholinergic agents
How does a nurse who has been providing home care to a terminally ill client know that the client's condition is beginning to deteriorate? apical pulse reaches 100 beats/minute skin appears red and flushed urine output increases facial muscles contract
apical pulse reaches 100 beats/minute
A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurses best answer? A) Have your heart checked regularly. B) Stop smoking as soon as possible. C) Get medication to bring down your sodium levels. D) Eat a nutritious diet
b
A nurse is caring for a patient with impaired renal function. A creatinine clearance measurement has been ordered. The nurse should facilitate collection of what samples? A) A fasting serum potassium level and a random urine sample B) A 24-hour urine specimen and a serum creatinine level midway through the urine collection process C) A BUN and serum creatinine level on three consecutive mornings D) A sterile urine specimen and an electrolyte panel, including sodium, potassium, calcium, and phosphorus values
b
The nurse is teaching a health class about UTIs to a group of older adults. What characteristic of UTIs should the nurse cite? A) Men over age 65 are equally prone to UTIs as women, but are more often asymptomatic. B) The prevalence of UTIs in men older than 50 years of age approaches that of women in the same age group. C) Men of all ages are less prone to UTIs, but typically experience more severe symptoms. D) The prevalence of UTIs in men cannot be reliably measured, as men generally do not report UTIs
b
Dipstick testing of an older adult patients urine indicates the presence of protein. Which of the following statements is true of this assessment finding? A) This finding needs to be considered in light of other forms of testing. B) This finding is a risk factor for urinary incontinence. C) This finding is likely the result of an age-related physiologic change. D) This result confirms that the patient has diabetes. Select all that apply.
bcd
As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply. A) INR above 1.0 B) Recent intracranial pathology C) Sudden symptom onset D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission
bde
A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient? A) Bathe daily and keep the perineal region clean. B) Avoid voiding immediately after sexual intercourse. C) Drink liberal amounts of fluids. D) Void at least every 6 to 8 hours
c
A nurse is aware of the high incidence and prevalence of fluid volume deficit among older adults. What related health education should the nurse provide to an older adult? A) If possible, try to drink at least 4 liters of fluid daily. B) Ensure that you avoid replacing water with other beverages. C) Remember to drink frequently, even if you dont feel thirsty. D) Make sure you eat plenty of salt in order to stimulate thirst
c
A nurse is working with a female patient who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment? A) Clearly explain the potential benefits of pelvic floor muscle exercises. B) Ensure the patient knows that surgery will be required if the exercises are unsuccessful. C) Arrange for biofeedback when the patient is learning to perform the exercises. D) Contact the patient weekly to ensure that she is performing the exercises consistently.
c
A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed? A) The circumference of the stoma B) The narrowest part of the stoma C) The widest part of the stoma D) Half the width of the stoma
c
A patient has had her indwelling urinary catheter removed after having it in place for 10 days during recovery from an acute illness. Two hours after removal of the catheter, the patient informs the nurse that she is experiencing urinary urgency resulting in several small-volume voids. What is the nurses best response? A) Inform the patient that urgency and occasional incontinence are expected for the first few weeks post-removal. B) Obtain an order for a loop diuretic in order to enhance urine output and bladder function. C) Inform the patient that this is not unexpected in the short term and scan the patients bladder following each void. D) Obtain an order to reinsert the patients urinary catheter and attempt removal in 24 to 48 hours.
c
The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patients plan of care? A) The patients hip joint should be maintained in a flexed position. B) The patient should be in a supine position unless ambulating. C) The patient should be placed in a prone position for 15 to 30 minutes several times a day. D) The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion
c
The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patients mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurses most appropriate action? A) Position the patient in the high Fowlers position as tolerated. B) Administer osmotic diuretics as ordered. C) Participate in interventions to increase cerebral perfusion pressure. D) Prepare the patient for craniotomy
c
The nurse is caring for a patient suspected of having renal dysfunction. When reviewing laboratory results for this patient, the nurse interprets the presence of which substances in the urine as most suggestive of pathology? A) Potassium and sodium B) Bicarbonate and urea C) Glucose and protein D) Creatinine and chloride
c
The nurse is caring for a patient who had a brush biopsy 12 hours ago. The presence of what assessment finding should prompt the nurse to notify the physician? A) Scant hematuria B) Renal colic C) Temperature 100.2F orally D) Infiltration of the patients intravenous catheter
c
The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the patient? A) Limit oral fluid intake for 1 to 2 days. B) Report the presence of fine, sand like particles through the nephrostomy tube. C) Notify the physician about cloudy or foul-smelling urine. D) Report any pink-tinged urine within 24 hours after the procedure
c
The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor? A) Solumedrol B) Dextromethorphan C) Dexamethasone D) Furosemide
c
The nurse is caring for a patient with a nursing diagnosis of deficient fluid volume. The nurses assessment reveals a BP of 98/52 mm Hg. The nurse should recognize that the patients kidneys will compensate by secreting what substance? A) Antidiuretic hormone (ADH) B) Aldosterone C) Renin D) Angiotensin
c
The nurse is caring for a patient with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a patient with an indwelling catheter? A) Vigorously clean the meatus area daily. B) Apply powder to the perineal area twice daily. C) Empty the drainage bag at least every 8 hours. D) Irrigate the catheter every 8 hours with normal saline
c
The staff educator is giving a class for a group of nurses new to the renal unit. The educator is discussing renal biopsies. In what patient would the educator tell the new nurses that renal biopsies are contraindicated? A) A 64-year-old patient with chronic glomerulonephritis B) A 57-year-old patient with proteinuria C) A 42-year-old patient with morbid obesity D) A 16-year-old patient with signs of kidney transplant rejection
c
During a home care visit to a client in hospice, the client's spouse reveals to the nurse an understanding that the client's death is inevitable. Recognizing the spouse is exemplifying the Kübler-Ross stage of acceptance, which statement by the nurse is most appropriate? "Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse." "Have you thought about what you will do when you find your spouse after he has died?" "Make sure you have made previous arrangements with the funeral home for burial arrangements." "I would make arrangements to have all your children present for the death vigil."
"Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse." *openended
A client with newly diagnosed renal cancer is questioning why detection was delayed. Which is the best response by the nurse? "Squamous cell carcinomas do not present with detectable symptoms." "You should have sought treatment earlier." "Very few symptoms are associated with renal cancer." "Painless gross hematuria is the first symptom in renal cancer."
"Very few symptoms are associated with renal cancer."
The nurse knows that electrocardiogram (ECG) characteristics of atrial fibrillation include what? Atrial rate of 300 to 400 Normal PR interval Regular rhythm P wave resent before each QRS
Atrial rate of 300 to 400
The nurse is preparing a client for upcoming electrophysiology (EP) studies and possible ablation for treatment of atrial tachycardia. What information will the nurse include in the teaching? During the procedure, the dysrhythmia will be reproduced under controlled conditions. The procedure will occur in the operating room under general anesthesia. The procedure takes less time than a cardiac catheterization. After the procedure, the dysrhythmia will not recur.
During the procedure, the dysrhythmia will be reproduced under controlled conditions.
The nurse is conducting a community education program on malignant melanoma. The nurse knows that the participants understand the teaching when they identify which characteristic as a risk factor? History of suntans Dark skin Mediterranean descent Family history of pancreatic cancer
Family history of pancreatic cancer
The nurse receives a client from the postanesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? Select all that apply. Fever Blood loss Sleep Hypoglycemia Anxiety
Fever Anxiety Blood loss
Age-related changes in the neurologic system must be carefully assessed. Which of the following changes does the nurse expect to find in some degree depending on the patient's age and medical condition? Select all that apply. Hyper-reactive deep tendon reflexes Decreased muscle mass Increased sensitivity to heat and cold Stage IV sleep is prolonged Increased sensitivity of taste buds Reduced papillary responses
Increased sensitivity to heat and cold Reduced papillary responses Decreased muscle mass
A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected? Temporal lobe Inferior posterior frontal areas Posterior frontal area Parietal-occipital area
Inferior posterior frontal areas
A nurse is teaching a client about the rationale for administering allopurinol with chemotherapy. Which example would be the bestteaching by the nurse? It stimulates the immune system against the tumor cells. It treats drug-related anemia. It prevents alopecia. It lowers serum and uric acid levels.
It lowers serum and uric acid levels.
A client has a squamous cell carcinoma removed from the right lower leg. After the surgery, the nurse reviews instructions for care of the pressure dressing and provides health information about the cancer. Which statements are correct regarding squamous cell carcinoma? Select all that apply. It is the third most common of all three types of skin cancer. It is an invasive carcinoma. It can develop from a keratosis. It is responsible for approximately 4,000 deaths per year. It requires follow-up examinations every 3 months for 1 year.
It requires follow-up examinations every 3 months for 1 year. It is an invasive carcinoma. It can develop from a keratosis. It is responsible for approximately 4,000 deaths per year.
A client with long-term breast cancer who was recently enrolled in a hospice program demonstrates signs and symptoms of clinical depression. Which action by the hospice nurse is appropriate? Educate the client that depression is expected. Perform a thorough pain assessment. Ask the client whether she is planning to hurt herself. Explain that antidepressants are not indicated for the client.
Perform a thorough pain assessment.
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken? Perform a vision field assessment. Reposition the tray and plate. Assist the client with feeding. Know this is a normal finding for CVA.
Perform a vision field assessment.
A client is coming to the office to have a growth removed by the doctor. The client asks "What does cryosurgery do to the growth?" What is the correct response? Removes the entire growth Through the application of extreme cold, the tissue is destroyed. Freezes the growth, so the physician can remove it at the next appointment Lasers the growth off
Through the application of extreme cold, the tissue is destroyed.
A nurse is preparing a patient diagnosed with benign prostatic hypertrophy (BPH) for a lower urinary tract cystoscopic examination. The nurse informs the patient that the most common temporary complication experienced after this procedure is what? A) Urinary retention B) Bladder perforation C) Hemorrhage D) Nausea
a
Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed? Ataxia Clonus Rigidity Flaccidity
clonus
The critical care nurse is giving end-of-shift report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? Comatose Somnolence Stupor Normal
comatose
A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active range of motion (ROM) exercises with the affected hand. How should the nurse best respond? A) Liaise with the physical therapist to ensure that the patient is performing exercises safely. B) Validate the patients efforts to increase blood perfusion to the graft site. C) Remind the patient that ROM exercises should be passive, not active. D) Remind the patient of the need to immobilize the graft to facilitate healing.
d
A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having difficulty voiding? A) Use a slipper bedpan. B) Apply a cold compress to the perineum. C) Have the patient lie in a supine position. D) Provide privacy for the patient
d
An oncology nurse is caring for a patient who has developed erythema following radiation therapy. What should the nurse instruct the patient to do? A) Periodically apply ice to the area. B) Keep the area cleanly shaven. C) Apply petroleum jelly to the affected area. D) Avoid using soap on the treatment area.
d
A patient is diagnosed with malignant melanoma that directly invades the adjacent dermis (vertical growth). The nurse knows that this type of melanoma has a poor prognosis. Which of the following is most likely the type of melanoma described in this scenario? Superficial spreading Lentigo-maligna Nodular melanoma Acral-lentiginous
Nodular melanoma
A creatinine level has been ordered. The nurse prepares to: Obtain a blood specimen. Collect the client's urine for 24 hours. Obtain a clean catch urine. Straight cath for a specimen.
Obtain a blood specimen.
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? A) Evidence of hemorrhagic stroke B) Blood pressure of 180/110 mm Hg C) Evidence of stroke evolution D) Previous thrombolytic therapy within the past 12 months
a
A patient is undergoing diagnostic testing for a suspected urinary obstruction. The nurse should know that incomplete emptying of the bladder due to bladder outlet obstruction can cause what? A) Hydronephrosis B) Nephritic syndrome C) Pylonephritis D) Nephrotoxicity
a
A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason? A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. B) Intake and output calculations are essential and the laboratory will calculate the precise urine output produced by this patient. C) A creatinine clearance study may be ordered at a later time and the laboratory will hold all urine until it is determined if the test will be necessary. D) There is great concern about electrolyte imbalances and the laboratory will monitor the urine for changes in potassium and sodium concentrations.
a
A nurse is working with a patient who will undergo invasive urologic testing. The nurse has informed the patient that slight hematuria may occur after the testing is complete. The nurse should recommend what action to help resolve hematuria? A) Increased fluid intake following the test B) Use of an OTC diuretic after the test C) Gentle massage of the lower abdomen D) Activity limitation for the first 12 hours after the test
a
A nurse knows that specific areas in the ureters have a propensity for obstruction. Prompt management of renal calculi is most important when the stone is located where? A) In the ureteropelvic junction B) In the ureteral segment near the sacroiliac junction C) In the ureterovesical junction D) In the urethra
a
A patient asks the nurse why kidney problems can cause gastrointestinal disturbances. What relationship should the nurse describe? A) The right kidneys proximity to the pancreas, liver, and gallbladder B) The indirect impact of digestive enzymes on renal function C) That the peritoneum encapsulates the GI system and the kidneys D) The left kidneys connection to the common bile duct
a
A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include? A) Deficient Knowledge about Early Signs of Melanoma B) Chronic Pain Related to Surgical Excision and Grafting C) Depression Related to Reconstructive Surgery D) Anxiety Related to Lack of Social Support
a
A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family? A) The patient should mobilize as soon as she is physically able. B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C) The patient should remain on bed rest until she expresses a desire to mobilize. D) Lack of mobility will greatly increase the patients risk of stroke recurrence
a
A patient with elevated BUN and creatinine values has been referred by her primary physician for further evaluation. The nurse should anticipate the use of what initial diagnostic test? A) Ultrasound B) X-ray C) Computed tomography (CT) D) Nuclear scan
a
Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patients plan of care? A) Supervise the patients activities of daily living closely. B) Initiate early ambulation to prevent complications of immobility. C) Provide a high-calorie, low-protein diet. D) Perform all of the patients hygiene and feeding.
a
A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection-related death in oncology patients? A) Encourage several small meals daily. B) Provide skin care to maintain skin integrity. C) Assist the patient with hygiene, as needed. D) Assess the integrity of the patients oral mucosa regularly.
b
A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patients safety during mobilization, the nurse should perform what action? A) Support the patients full body weight with a waist belt during ambulation. B) Have a colleague follow the patient closely with a wheelchair. C) Avoid mobilizing the patient in the early morning or late evening. D) Ensure that the patients family members do not participate in mobilization.
b
A patient with a chronic diabetic wound is being discharged after receiving a skin graft to aid wound healing. What direction should the nurse include in home care instructions? A) Gently massage the graft site daily to promote perfusion. B) Protect the graft from direct sunlight and temperature extremes. C) Protect the graft site from any form of moisture for at least 12 weeks. D) Apply antibiotic ointment to the graft site and donor site daily
b
A patient with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acidbase balance? A) Sequestering free hydrogen ions in the nephrons B) Returning bicarbonate to the bodys circulation C) Returning acid to the bodys circulation D) Excreting bicarbonate in the urine
b
A patient with a history of progressively worsening fatigue is undergoing a comprehensive assessment which includes test of renal function relating to erythropoiesis. When assessing the oxygen transport ability of the blood, the nurse should prioritize the review of what blood value? A) Hematocrit B) Hemoglobin C) Erythrocyte sedimentation rate (ESR) D) Serum creatinine
b
A patient with renal failure secondary to diabetic nephropathy has been admitted to the medical unit. What is the most life-threatening effect of renal failure for which the nurse should monitor the patient? A) Accumulation of wastes B) Retention of potassium C) Depletion of calcium D) Lack of BP control
b
The nurse caring for a patient with suspected renal dysfunction calculates that the patients weight has increased by 5 pounds in the past 24 hours. The nurse estimates that the patient has retained approximately how much fluid? A) 1,300 mL of fluid in 24 hours B) 2,300 mL of fluid in 24 hours C) 3,100 mL of fluid in 24 hours D) 5,000 mL of fluid in 24 hours
b
The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem? A) Cognitive deficits B) Impaired wound healing C) Cardiac tamponade D) Tumor lysis syndrome
b
The nurse is caring for a patient scheduled for renal angiography following a motor vehicle accident. What patient preparation should the nurse most likely provide before this test? A) Administration of IV potassium chloride B) Administration of a laxative C) Administration of Gastrografin D) Administration of a 24-hour urine test
b
The nurse is reviewing the electronic health record of a patient with a history of incontinence. The nurse reads that the physician assessed the patients deep tendon reflexes. What condition of the urinary/renal system does this assessment address? A) Renal calculi B) Bladder dysfunction C) Benign prostatic hyperplasia (BPH) D) Recurrent urinary tract infections (UTIs)
b
A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patients care, the nurse would expect to administer what priority medication? A) Hydrochlorothiazide (HydroDIURIL) B) Furosemide (Lasix) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)
c
A patient requires a full-thickness graft to cover a chronic wound. How is the donor site selected? A) The largest area of the body without hair is selected. B) Any area that is not normally visible can be used. C) An area matching the color and texture of the skin at the surgical site is selected. D) An area matching the sensory capability of the skin at the surgical site is selected.
c
A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1F (38.4C). How should the nurse best respond to the patient? A) Remind the patient that renal calculi have a noninfectious etiology and that a fever is unrelated to their recurrence. B) Remind the patient that occasional febrile episodes are expected following ESWL. C) Tell the patient to report to the ED for further assessment. D) Tell the patient to monitor his temperature for the next 24 hours and then contact his urologists office.
c
A patient with a recent history of nephrolithiasis has presented to the ED. After determining that the patients cardiopulmonary status is stable, what aspect of care should the nurse prioritize? A) IV fluid administration B) Insertion of an indwelling urinary catheter C) Pain management D) Assisting with aspiration of the stone
c
Diagnostic testing of an adult patient reveals renal glycosuria. The nurse should recognize the need for the patient to be assessed for what health problem? A) Diabetes insipidus B) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) C) Diabetes mellitus D) Renal carcinoma
c
A patient has experienced excessive losses of bicarbonate and has subsequently developed an acidbase imbalance. How will this lost bicarbonate be replaced? A) The kidneys will excrete increased quantities of acid. B) Bicarbonate will be released from the adrenal medulla. C) Alveoli in the lungs will synthesize new bicarbonate. D) Renal tubular cells will generate new bicarbonate.
d
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses
d
The nurse is orienting a new nurse to the oncology unit. When reviewing the safe administration of antineoplastic agents, what action should the nurse emphasize? A) Adjust the dose to the patients present symptoms. B) Wash hands with an alcohol-based cleanser following administration. C) Use gloves and a lab coat when preparing the medication. D) Dispose of the antineoplastic wastes in the hazardous waste receptacle.
d
