Mrs V Exam 3

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.)

"You will not need vascular access to perform PD." "There is less restriction of protein and fluids." "You have flexible scheduling for the exchanges."

Patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include

Fluid resuscitation

Which menu choice indicates that the patient is implementing plans to choose high-calorie, high-protein foods?

Fried chicken with potatoes and gravy

What information will the nurse include for an overweight 35-year-old woman who is starting a weight-loss plan?

Low carbohydrate diets lead to rapid weight loss but are difficult to maintain.

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client's spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.)

Lower sodium Lower potassium Higher calories

A 65 year old male is admitted to the ICU with syndrome of inappropriate antidiuretic hormone (SIADH) resultant from a brain tumor in his frontal lobe. Serum sodium is 115 mEq/L. What is the priority of nursing care for the patient?

Maintaining a safe environment

The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.)

Malnutrition Ascites Disseminated intravascular coagulation

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.)

Man with prostate cancer Woman with blood clots in the urinary tract Client with ureterolithiasis

Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)?

Many over-the-counter (OTC) medications can cause constipation. Bulk-forming laxatives are an excellent source of fiber. Walking or cycling frequently will help bowel motility. A good time for a bowel movement may be after breakfast.

Nurse is assessing a client who is 12 hours postoperative for the removal of a benign pituitary brain tumor and has been placed in a drug induced coma with normal saline infusing at 125 mL/hr. The client's heart rate is 90 bpm, BP is 100/60 and the indwelling catheter has drained 250 mL of pale yellow urine in the last 30 mins into the collection bag. After reporting these findings to the HCP which action should the nurse implement?

Prepare to administer desmopressin (DDAVP

Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply.)

Protein Red blood cells

A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.)

Proteinuria Hypoalbuminemia Lipiduria

A 56-year-old female patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect?

Recent weight gain

The nurse working in a trauma center administers blood products to a severely hemorrhaging trauma patient in a 1:1:1 ratio. Which blood products does the nurse include in this transfusion protocol? (Select all that apply.)

Red blood cells Platelets Plasma

A nurse reviews laboratory results for a client with glomerulonephritis. The client's glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.)

Reduced GFR Potential for fluid overload

Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome?

Severe, throbbing pain in the affected area

When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.)

Severity of blood loss Hemodynamic stability Necessity for fluid resuscitation

You are providing patient education with active hepatitis B. What will you include in the discharge instructions.

follow a diet low in fat and high in carbs do not share razors, utilences, touthbrushes and other types of personal hygine

Numbers of white blood cells (WBCs) are increased in circumstances of (Select all that apply.)

inflammation allergy invasion by pathogenic organisms.

Which nursing intervention should be initiated on all patients with syndrome of inappropriate antidiuretic hormone (SIADH)?

initiate seizure precautions

Autoimmunity can result from (Select all that apply.)

injury to tissues infection malignancy unknown causes.

Accepted treatments for disseminated intravascular coagulation (DIC) may require (Select all that apply.)

platelet infusions administration of fresh frozen plasma cryoprecipitate packed RBCs.

SATA- The nurse is caring for a patient with chronic pancreatitis. Which assessment findings are related to this disease process.

polyphagia jaundice polydipisia

The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: (Select all that apply.)

proton pump inhibitors anticholinergic drugs antacids.

The nurse is caring for a patient who is a recent recipient of a kidney transplant. Which intervention should the nurse perform in the immediate post op period. SATA

record CVP monitor pt for hyponatremia and hypokalemia

Continuous venovenous hemofiltration is used to

remove fluids and solutes through the process of convection.

Continuous venovenous hemodialysis is used to

remove plasma water and solutes by adding dialysate.

Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used to

remove plasma water in cases of volume overload.

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.)

"I need to ask for an antibiotic when scheduling a dental appointment." "I'll need to check my blood sugar often to prevent hypoglycemia." "The dose of my pain medication may have to be adjusted." "I should watch for bleeding when taking my anticoagulants."

In caring for the patient who has a coagulopathy, the nurse should (Select all that apply.)

assess fluids for occult blood. limit invasive procedures. weigh dressings to assess blood loss.

After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

"I will take this medication with my breakfast each morning.

A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond?

"Less protein in the diet will help prevent confusion associated with liver failure."

The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.)

"My weight should be maintained at a body mass index of 30." "I can continue to take an aspirin every 4 to 8 hours for my pain." "I really only need to drink a couple of glasses of water each day."

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)?

"Ranitidine decreases gastric acid secretion."

Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply)?

Avoid commercial salt substitutes. Take phosphate-binders with each meal. Choose high-protein foods for most meals.

You are providing education to a patient with CKD about calcium acetate. what statement made by the patient indicates they understood your teaching about the medication

the med will help prevent my phosphate level from increasing take this med with meals or immediately after

A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the nurse include in this client's discharge teaching? (Select all that apply.)

"Take your blood pressure every morning." "Weigh yourself at the same time each day." "Contact your provider if you have visual disturbances."

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

"The best time to take the enzymes is immediately after I have a meal or a snack."

Which of the nurse's assigned patients should be referred to the dietitian for a complete nutritional assessment (select all that apply)?

A 23-year-old who has a history of fluctuating weight gains and losses A 64-year-old who is admitted for débridement of an infected surgical wound A 48-year-old with rheumatoid arthritis who takes prednisone (Deltasone) daily

Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.)

ADH deficiency ADH insensitivity

The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.)

Acidosis Volume overload Hyperkalemia Uremia

A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.)

Adjust the rate of extracorporeal blood flow. Place the client in the Trendelenburg position. Administer a 250-mL bolus of normal saline.

After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)?

Administer hepatitis B vaccine. Test for antibodies to hepatitis B. Give hepatitis B immune globulin.

To evaluate an obese patient for adverse effects of lorcaserin (Belviq), which action will the nurse take?

Ask about bowel movements.

When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include?

Blood glucose test

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.)

Blood glucose: 524 mg/dL HCO3—: 10 mEq/L pH: 7.23

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?

Blood pressure 90/48 mm

A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.)

Bloody drainage at site Foul-smelling drainage Urine draining from site

Which assessment action will help the nurse determine if an obese patient has metabolic syndrome?

Check the patient's blood pressure.

Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.)

Graduated compression stockings Heparin or low-molecular weight heparin for patients at risk Sequential compression devices

What duties are assumed by a state's board of nursing? (Select all that apply.)

Grants nursing licensure. Assigns disciplinary action when the nurse acts in a manner that results in harm to a patient. Assures qualified members are appointed to the board.

A 63-year-old male patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the physician?

Heart rate 102 beats/minute

Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.)

Heredity Medications Sickle cell disease

Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.)

Hypotension Dysrhythmias

A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider?

Crackles are heard halfway up the posterior chest.

Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.)

Crush injury to right arm Lightning strike of the left arm and chest

A patient has been admitted with muscle trauma and crush injuries. The nurse understandsthat this patient is at high risk for the development of acute kidney injury secondary torhabdomyolysis. Which findings would suggest the patient is developing this complication?(Select all that apply.)

Dark tea colored urine increased serum creatine kinase level decreased urine output

Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.)

Dilated vessels Tortuous vessels Constricted vessels

Patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a (DVT) is diagnosed with (HIT) when the platelet level drops to 110,000. Which action will the nurse include in the plan of care?

Discontinue the heparin infusion

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider?

Drainage from a fistula

Which statements concerning licensure as a registered nurse are correct? (Select all that apply.)

Each nurse practice act describes requirements for initial licensure. Candidates for licensure must present proof of graduation as required by the state.

A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/L. Which action should the nurse take?

Encourage the client to drink more fluids.

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?

Fewer episodes of bleeding varices

A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? (Select all that apply.)

Flank pain Increased abdominal girth Hematuria

Which of the following medications would not be administered to a patient experiencing pancreatitis.

Insulin Dextrose

Patient has been admitted after surgery for removal of a brain tumor. The nurse suspects the patient may be developing diabetes insipidus (DI). Which findings would confirm the nurses suspicion?

Intense thirst and passage of excessively large quantities of dilute urine

Noninvasive diagnostic procedures used to determine kidney function include which of the following? (Select all that apply.)

Kidney, ureter, bladder (KUB) x-ray Renal ultrasound Magnetic resonance imaging (MRI)

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F. The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.)

Notify the blood bank Notify the provider Stop the transfusion

A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow?

Overflow incontinence

Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?

Palpable abdominal mass

The nurse reviews a patient's medical record and suspects (HIT). Which finding supports the nurse's conclusion?

Patient has a platelet count of 100,000/mL

Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.)

Prevention of hypothermia Administration of fresh frozen plasma as ordered Administration of calcium as ordered

A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective?

Stools test negative for occult blood.

Which assessment should the nurse perform first for a patient who just vomited bright red blood?

Taking the blood pressure (BP) and pulse

Which finding for a patient who has been taking orlistat (Xenical) is most important to report to the health care provider?

The patient is pale and has many bruises.

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider?

The patient's lungs have crackles audible to the midchest.

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury?

Urine output of 100 mL in 4 hours Large amount of sediment in the urine Blood pressure of 90/60 mm Hg

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?

Urine output via indwelling urinary catheter is 20 mL/hr

The nurse is caring for a patient with heparin induced thrombocytopenia (HIT). Nurse knows the patient is at high risk for bleeding and injury. Which interventions would be included in the plan of care? SATA

Use draw sheets when repositioning the patient in bedAvoid IM injectionsShave with an electric shaver onlyUse a soft-bristled toothbrush when providing mouth care

Which information in this male patient's electronic health record as shown in the accompanying figure will the nurse use to confirm that the patient has metabolic syndrome (select all that apply)?

Waist size Blood glucose

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to

administer IV fluids.

The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.)

bladder catheterization ureteral stenting placement of nephrostomy tubes.

The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.)

bladder catheterization. ureteral stenting placement of nephrostomy tubes.

Causes of anemia include which of the following: (Select all that apply.)

blood loss impaired production of red blood cells increased destruction of red blood cells.

When dealing with hematological malignancies, therapies that have significant management roles include which of the following: (Select all that apply.)

chemotherapy biotherapy bone marrow transplantation radiation

SATA Which clinical manifestations of inflammatory bowel syndrome are common to patients with both ulcerative colitis and chrones disease.

diarrheal stools cramping and abdominal pain

The patient is in the critical care unit and will receive dialysis this morning. The nurse will: (Select all that apply.)

evaluate morning laboratory results and report abnormal results assess the dialysis access site and report abnormalities weigh the patient to monitor fluid status

The patient is in the critical care unit and will receive dialysis this morning. The nurse will: (Select all that apply.)

evaluate morning laboratory results and report abnormal results. assess the dialysis access site and report abnormalities. give all medications except for antihypertensive medications.

Inflammation is initiated by cellular injury and (Select all that apply.)

is necessary for tissue repair. is harmful when uncontrolled.

SATA- The nurse is caring for a patient with colorectal cancer.Which assessment finding indicates the possibility of metastasis

lower back pain elevated bilirubin level Ascities

Nursing priorities for the management of acute pancreatitis include: (Select all that apply.)

managing respiratory dysfunction assessing and maintaining electrolyte balance utilizing supportive therapies aimed at decreasing gastrin release.

Nursing priorities for the management of acute pancreatitis include: (Select all that apply.)

managing respiratory dysfunction. assessing and maintaining electrolyte balance. utilizing supportive therapies aimed at decreasing gastrin release.

Identify which substances would indicate a problem with renal function. (Select all that apply). ASK MRS. V ABOUT THIS QUESTION (WHAT ABOUT URIC ACID?)

protein red blood cells globulin

A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. The most appropriate action by the nurse is to

recheck the capillary blood glucose in 4 to 6 hours.

When a 72-year-old patient is diagnosed with achalasia, the nurse will teach the patient that

treatment may include endoscopic procedures