MSIII-Questions
The nurse is working with a client newly diagnosed with chronic kidney disease (CKD) to set up a schedule for hemodialysis. The client states, "This is impossible! How can I even think about leading a normal life again if this is what I'm going to have to do?" The nurse determines that the client is exhibiting which problem?1.Anger 2.Projection 3.Depression 4.Withdrawal
1
The nurse is discussing the plan of care with a client receiving dialysis. The nurse understands what aspect of care is a priority for this client? 1. Eating fruits and vegetables. 2. Monitoring fluid intake. 3. Daily exercise. 4. Monitoring output.
2
The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension? 1.Flat neck veins 2.Abdominal distention 3.Hemoglobin of 14.2 g/dL (142 mmol/L) 4.Platelet count of 600,000 mm3 (600 × 109/L)
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
The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. 1.Jaundice 2.Flu-like symptoms 3.Clay-colored stools 4.Elevated bilirubin levels 5.Dark or tea-colored urine
1,3,4,5
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
4
The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? 1."I have epigastric pain radiating to my neck." 2."I have severe abdominal pain that is relieved after vomiting." 3."My temperature has been running between 96º F (35.5º C) and 97º F (36.1º C)." 4."I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."
4
The nurse is reviewing the laboratory test results for a client and notes that the albumin level is 3.0 g/dL (30 g/L). The nurse understands that this laboratory value would be noted in which condition? 1.Diarrhea 2.Dehydration 3.Multiple myeloma 4.Cirrhosis of the liver
4
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
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
The client in chronic kidney disease is receiving epoetin alfa. The nurse should monitor this client for which side/adverse effect of this medication? 1.Fever 2.Depression 3.Bradycardia 4.Hypertension
4 (Subcu)
A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply. 1.Peritoneal dialysis 2.Analysis of the urinary stone 3.Intravenous opioid analgesics 4.Insertion of a nephrostomy tube 5.Placement of a ureteral stent with ureteroscopy
4,5
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1.Diarrhea 2.Black, tarry stools 3.Hyperactive bowel sounds 4.Gray-blue color at the flank 5.Abdominal guarding and tenderness 6.Left upper quadrant pain with radiation to the back
4,5,6
A 62-year-old client was admitted 2 days ago with traumatic injuries and hypovolemic shock. Which lab result is most important for the nurse to report to the health care provider immediately? A. Serum sodium 132 mEq/L (mmol/L) B. Serum potassium 6.9 mEq/L (mmol/L) C. Blood urea nitrogen 24 mg/dL (mmol/L) D. Hematocrit 32% (0.32 volume fraction); hemoglobin 9.2 g/dL (92 g/L)
B
A client who performs continuous ambulatory peritoneal dialysis at home reports that the drainage (effluent) has become cloudy in the past 24 hours. What is the priority nursing action? A. Remove the peritoneal catheter. B. Notify the nephrology health care provider. C. Obtain a sample of effluent for culture and sensitivity. D. Teach the client that effluent should be clear or slightly yellow.
C
A young adult client admitted with a diagnosis of cholecystitis from cholelithiasis has severe abdominal pain, nausea, and vomiting. Based on these assessment findings, which client problem is the highest priority for nursing intervention at this time? A. Anxiety B. Risk for dehydration C. Acute pain D. Malnutrition
C
The nurse is caring for a patient with cirrhosis who has hepatic encephalopathy. Which assessment finding should the nurse report to the primary health care provider? A. Fatigue B. Difficulty sleeping C. Seizure D. Disorientation
C
A client with a medical diagnosis of cirrhosis has been admitted to a medical unit, and the nurse is doing an assessment. What complaint from the client requires immediate follow-up? 1. Bloody expectorant with coughing episodes. 2. Jeans cannot zip because of enlarged abdomen. 3. Swelling in the feet and lower legs. 4. Yellowing of the eyes and mucous membranes.
1
A client with acute glomerulonephritis has had a urinalysis sample sent to the laboratory. The report reveals the presence of hematuria and proteinuria. The nurse interprets these results as which condition? 1.Consistent with glomerulonephritis 2.Inconsistent with glomerulonephritis 3.Unclear; no conclusion can be drawn 4.Indicative of impending acute kidney injury
1
A client with candida cystitis is being treated with amphotericin B bladder irrigations. Which action should the nurse perform before delivery of the first dose? 1. Evaluate BUN and Creatinine levels. 2. Assess the lung sounds. 3. Determine the level of consciousness. 4. Assess code status.
1
A client with chronic kidney disease (CKD) has been taking aluminum hydroxide gel. On the basis of this information, the nurse determines that the client is most at risk for which problem? 1.Constipation 2.Dehydration 3.Inability to tolerate activity 4.Impaired physical mobility
1
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 chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication? 1.Hematocrit of 33% (0.33) 2.Platelet count of 400,000 mm3 (400 × 109/L) 3.White blood cell count of 6000 mm3 (6.0 × 109/L) 4.Blood urea nitrogen level of 15 mg/dL (5.4 mmol/L)
1
A client with chronic pancreatitis needs information on dietary modification to manage the health problem. Which item in the diet should the nurse teach the client to limit? 1.Fat 2.Protein 3.Carbohydrate 4.Water-soluble vitamins
1
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 acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action? 1.Sitting up 2.Lying flat 3.Leaning forward 4.Drawing the legs to the chest
2
.A client is admitted with ascites from liver failure. Spironolactone 100 mg is administered. Which sign or symptom would designate a serious complication for the client? 1. Blurry vision 2. Low potassium 3. Increased thirst. 4. Leg pain
3
A client has been diagnosed with polycystic kidney disease. On assessment of the client, the nurse should observe for which most common manifestation of this disorder?1.Headache 2.Hypotension 3.Flank pain and hematuria 4.Complaints of low pelvic pain
3
A client is being discharged to home while recovering from acute kidney injury (AKI). Reduced dietary intake of which substance indicates to the nurse that the client understands the dietary teaching? 1.Fats 2.Vitamins 3.Potassium 4.Carbohydrates
3
A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication? 1.Ibuprofen 2.Ranitidine 3.Acetaminophen 4.Acetylsalicylic acid
3
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
A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5° C (101.2° F). Which nursing action is most appropriate? 1.Encourage fluid intake. 2.Continue to monitor vital signs. 3.Notify the primary health care provider. 4.Monitor the site of the shunt for infection.
3
A client with pancreatitis and a nasogastric (NG) tube in place complains of nausea. Which of the following nursing interventions is most appropriate? 1. Administer antiemetic medicine. 2. Remove NG tube and insert a new one. 3. Aspirate the gastric contents with a syringe. 4. Irrigate the NG tube with distilled water
3
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
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
The nurse has completed teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse should determine that education was effective if the client states to record which parameters daily? 1.Pulse and respiratory rate 2.Amount of activity and sleep 3.Intake and output (I&O) and weight 4.Blood urea nitrogen (BUN) and creatinine
3
The nurse is admitting a client from the postanesthesia care unit who has had percutaneous nephrolithotomy for calculi in the renal pelvis. The nurse anticipates that the client's care will most likely involve monitoring which device? 1.Ureteral stent 2.Suprapubic tube 3.Nephrostomy tube 4.Jackson-Pratt drain
3
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1.Clamp the T-tube. 2.Irrigate the T-tube. 3.Document the findings. 4.Notify the primary health care provider.
3
A client with chronic kidney disease is receiving ferrous sulfate. The nurse instructs the client that which finding is a common side/adverse effect associated with this medication? 1.Fatigue 2.Headache 3.Weakness 4.Constipation
4
A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the past 1½ weeks. The client has edema of the feet and ankles, and his abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time? 1.Difficulty with sleeping 2.Risk for skin breakdown 3.Difficulty with breathing 4.Excessive body fluid volume
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
Emergency Medical Services transports a known intravenous drug user to the Emergency Department. The client reports flu-like symptoms for the last week, jaundice, and inability to keep food down. What safety precautions should the nurse utilize? 1. Droplet precautions only. 2. Full gown, gloves, mask with shield. 3. Report the client to the CDC. 4. Standard precautions of gloves and handwashing
4
The nurse is preparing a client with stage 3 CKD for discharge. Which client statement indicates the need for further teaching? A. "I will be sure to attend my follow-up appointment with my nephrologist." B. "I will increase my protein intake so my body can heal." C. "I will weigh myself daily and call the doctor if my weight increases by 2 lb or more." D. "I will take my blood pressure each day and keep a daily log."
B
The nurse is reviewing the client's laboratory data prior to a nephrostomy tube insertion. Which data requires the nurse to take action? A. White blood cells in the urine B. INR of 2.1 C. Hematocrit 44% D. Creatinine 0.8 mg/dL
B
When assessing a client with acute glomerulonephritis, which question will the nurse ask to determine if the client is following best practices to slow progression of kidney damage? A. "Do you avoid contact sports while you are taking cyclosporine?" B. "How are you evaluating the amount of daily fluid you drink?" C. "Have you contacted anyone from our dialysis support services?" D. "Have you increased your protein intake to promote healing of the damaged nephrons?"
B
Which question will the nurse ask the client who has a urinary tract infection to assess the risk for pyelonephritis? A. "What drugs do you take for asthma?" B. "How long have you had diabetes?" C. "How much fluid do you drink daily?" D. "Do you take your antihypertensive drugs at night or in the morning?"
B
Which statement by the client who is prescribed to take pancreatic enzyme replacements indicates a need for further teaching by the nurse? A. "I need to take the enzymes at every meal and with snacks." B. "After taking the enzymes, I should drink a glass of water." C. "I should wipe my mouth in case any of the enzyme got on my lips." D. "I should chew each capsule carefully so that it works in my stomach."
D
The nurse is reviewing a client's record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding? 1.Elevated creatinine level 2.Decreased hemoglobin level 3.Decreased red blood cell count 4.Increased number of white blood cells in the urine
1
The nurse is reviewing the primary health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription requires follow-up by the nurse? 1.Full liquid diet 2.Morphine sulfate for pain 3.Nasogastric tube insertion 4.An anticholinergic medication
1
The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the primary health care provider? 1.Elevated serum bilirubin level 2.Below normal hemoglobin concentration 3.Elevated blood urea nitrogen (BUN) level 4.Elevated erythrocyte sedimentation rate (ESR)
1
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
Which finding noted in the client on continuous ambulatory peritoneal dialysis (CAPD) should be reported to the primary health care provider (PHCP)? 1.Cloudy yellow dialysate output 2.Client refusal to take the stool softener 3.Previous evening's dwell time of 8 hours 4.Peritoneal catheter site is not red, and the skin has grown around the cuff
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
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
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 her or his 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 has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1.Malaise 2.Dark stools 3.Weight gain 4.Left upper quadrant discomfort
1
A nurse is working in an outpatient dialysis unit and notices a reddened, skin infection on the right arm of a client. The client shares that it was a bug bite but has gotten worse since discharge from the hospital two weeks ago. What action should the nurse take next? 1. Apply gloves and explore the wound more closely. 2. Encourage the client to apply antibiotic cream and keep it covered. 3. Ask why the client was hospitalized. 4. Culture the wound.
1
Before providing care for a client in the late stages of chronic kidney disease (CKD), the nurse should review the results of which most relevant laboratory studies? 1.Serum potassium, serum calcium 2.Urinalysis, hematocrit, hemoglobin 3.Culture and sensitivity testing, serum sodium 4.Urine specific gravity, intravenous pyelogram
1
TThe nurse manager in a care center has identified an increase in the cases of pyelonephritis of its female residents over the last month. What should be included in a training session for staff in the care of these clients? 1. Reason for increased risk for pyelonephritis in older adult females. 2. The importance of cleaning the perineum back to front. 3. The need to provide a diet high in protein and vitamins. 4. Early recognition of lower abdominal pain.
1
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
The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? 1.Cream of wheat, blueberries, coffee 2.Sausage and eggs, banana, orange juice 3.Bacon, cantaloupe melon, tomato juice 4.Cured pork, grits, strawberries, orange juice
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 nailbeds of the fingers on the left hand.
1
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 nurse is caring for a client who has been diagnosed as having an acute kidney injury (AKI) due to intrarenal causes. What diagnostic test is most effective in confirming this diagnosis? 1.Renal biopsy 2.Ultrasonography 3.Computed tomography scan 4.Magnetic resonance imaging
1
The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence? 1.Inability to pass flatus 2.Loss of anal sphincter control 3.Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal margin
1
The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? 1.Inability to pass flatus 2.Loss of anal sphincter control 3.Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal margin
1
The nurse is caring for a client with biliary obstruction. The nurse interprets that obstruction of which passage is related to the client's condition? 1.Cystic duct 2.Liver canaliculi 3.Common bile duct 4.Right hepatic duct
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 cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food? 1.Pork 2.Milk 3.Chicken 4.Broccoli
1
The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item(s) are acceptable in the diet? 1.Baked fish 2.Fried chicken 3.Sauces and gravies 4.Fresh whipped cream
1
The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? 1."Does the pain in your stomach radiate to your back?" 2."Does the pain in your lower abdomen radiate to your hip?" 3."Does the pain in your lower abdomen radiate to your groin?" 4."Does the pain in your stomach radiate to your lower middle abdomen?"
1
The nurse is preparing to care for a client receiving peritoneal dialysis. Which should be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis? 1.Maintain strict aseptic technique. 2.Add heparin to the dialysate solution. 3.Change the catheter site dressing daily. 4.Monitor the client's level of consciousness.
1
The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid? 1.Chili 2.Bagel 3.Lentil soup 4.Watermelon
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 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 caring for a young client who reports being beaten in a street fight, with resultant acute kidney injury. What nursing actions would be appropriate? Select all that apply. 1. A thorough assessment to determine the extent of the client's injuries. 2. Dietary restrictions of potassium, phosphate, and sodium. 3. Fluid restriction of 600 mL plus previous 24-hour fluid loss. 4. Hourly serum BUN and creatinine levels. 5. Schedule a renal ultrasound as ordered.
1,2,3,5
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that apply. 1.Place the client on a cardiac monitor. 2.Notify the primary health care provider (PHCP). 3.Put the client on NPO (nothing by mouth) status except for ice chips. 4.Review the client's medications to determine whether any contain or retain potassium. 5.Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.
1,2,4
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1.Maintain NPO (nothing by mouth) status. 2.Encourage coughing and deep breathing. 3.Give small, frequent high-calorie feedings. 4.Maintain the client in a supine and flat position. 5.Give hydromorphone intravenously as prescribed for pain. 6.Maintain intravenous fluids at 10 mL/hr to keep the vein open.
1,2,5
The nurse is reviewing the urinalysis results for a client with glomerulonephritis. Which findings should the nurse expect to note? Select all that apply.1.Proteinuria 2.Hematuria 3.Positive ketones 4.A low specific gravity 5.A dark and smoky appearance of the urine
1,2,5
A client with chronic kidney disease 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. 1.What are the priority nursing actions? Select all that apply. 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
The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply. 1.Hemodialysis 2.Peritoneal dialysis 3.Kidney transplant 4.Bilateral nephrectomy 5.Intense immunosuppression therapy
1,3,4
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 nurse is caring for a client with suspected hepatitis. What diagnostic test results will assist in confirming this client's diagnosis? Select all that apply. 1.Leukopenia 2.Elevated hemoglobin 3.Elevated liver enzymes 4.Elevated serum bilirubin level 5.Elevated blood urea nitrogen (BUN) 6.Elevated serum erythrocyte sedimentation rate (ESR)
1,3,4,6
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1.Fever 2.Positive Cullen's sign 3.Complaints of indigestion 4.Palpable mass in the left upper quadrant 5.Pain in the upper right quadrant after a fatty meal 6.Vague lower right quadrant abdominal discomfort
1,3,5
The nurse is caring for a client with renal failure. The client is on a special diet and strict intake and output. What nursing assessments would the nurse do for this client? Select all that apply. 1. Daily weights. 2. Monitor appetite. 3. Monitor edema in the extremities. 4. Monitor bowel movements. 5. Monitor urine volume and characteristics.
1,3,5
A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. 1.Blood transfusions 2.Metabolic alkalosis 3.Bleeding or hemorrhage 4.Decreased sodium excretion 5.Ingestion of potassium in medications 6.Failure to restrict dietary potassium
1,3,5,6
The nurse is caring for a client with chronic kidney disease. The nurse plans care knowing that besides maintaining urinary elimination, the kidneys also are involved in what body processes? Select all that apply. 1.Help regulate blood pressure. 2.Encourage immunosuppression. 3.Stimulate liver to secrete enzymes. 4.Assist to regulate acid-base balance. 5.Convert vitamin D to an active form. 6.Produce erythropoietin for red blood cell synthesis
1,4,5,6
The nurse receives handoff report on each of these clients experiencing complications from untreated cystitis. Which clients should be managed first? Rank order the responses. 1. 81-year-old with nightly incontinence. 2. 28-year-old at 38 weeks gestation in preterm labor. 3. 54-year-old with flank pain and a temperature of 102°F (38.8°C). 4. 67-year-old with a GFR of 25%. 5. 32-year-old with cloudy yellow urine.
1. 54-year-old with flank pain and a temperature of 102°F (38.8°C). 2. 28-year-old at 38 weeks gestation in preterm labor. 3. 67-year-old with a GFR of 25%. 4. 32-year-old with cloudy yellow urine. 5. 81-year-old with nightly incontinence.
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 nurse in a dialysis unit is monitoring the client with chronic kidney disease (CKD). In what order would the nurse assess signs/symptoms and act to keep the client as comfortable as possible during peritoneal dialysis (PD)? Rank order the responses. 1. Development of crackles in the bases of both lungs. 2. Headache. 3. Itching and scratching of the lower extremities. 4. Nausea and vomiting. 5. Spreading hematoma around the peritoneal catheter.
1. Spreading hematoma around the peritoneal catheter. 2. Development of crackles in the bases of both lungs. 3. Nausea and vomiting. 4. Headache. 5. Itching and scratching of the lower extremities.
The nurse has a prescription to obtain a 24-hour urine collection in a client with a renal infection. Which actions should the nurse take when collecting this specimen? Select all that apply. 1.Explain the procedure to the client. 2.Save all subsequent voidings after the first void during the 24-hour period. 3.During the collection period, place the main container on ice or in a refrigerator. 4.Have the client void at the end time, and place this specimen in the main container. 5.Have the client void at the start time, and place this specimen in the main container.
1234
The nurse has taught the client with polycystic kidney disease about management of the disorder and prevention and recognition of complications. The nurse should determine that the client understands the instructions if the client states that which should be reported to the primary health care provider (PHCP)? Select all that apply. 1.Frequent urination 2.Burning on urination 3.A temperature of 100.6º F (38.1º C) 4.New-onset shortness of breath 5.A blood pressure of 105/68 mm Hg
1234
A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. 1.Orthopnea and dyspnea 2.Petechiae and ecchymosis 3.Inguinal or umbilical hernia 4.Poor body posture and balance 5.Abdominal distention and tenderness
1235
The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Monitor daily weight. 2.Measure abdominal girth. 3.Monitor respiratory status. 4.Place the client in a supine position. 5.Assist the client with care as needed.
1235
The nurse is caring for a client diagnosed with cirrhosis of the liver with portal hypertension. The client vomited 500 mL bright red emesis and states that he is feeling lightheaded. In which priority order should the nurse perform these interventions? Arrange the actions in the order they should be performed. All options must be used. Select the correct sequence number for each item. 1Apply oxygen. 2Check the client's blood pressure. 3Ensure that 2 large-bore intravenous lines are present with an isotonic solution infusing. 4Ask the client if he is taking any nonsteroidal anti-inflammatory medications.
1324
The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. 1.Elevated lipase level 2.Elevated lactase level 3.Elevated trypsin level 4.Elevated amylase level 5.Elevated sucrase level
134
A client diagnosed with polycystic kidney disease has been taught about the treatment plan for this disease. The nurse should determine that the client needs further teaching if the client states that which is included in the treatment plan? 1.Genetic counseling 2.Sodium restriction 3.Increased water intake 4.Antihypertensive medications
2
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
A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain? 1.Eating helps to decrease the pain. 2.The pain usually increases after vomiting. 3.The pain is mostly around the umbilicus and comes and goes. 4.The pain increases when the client sits up and bends forward.
2
A client is admitted with possible hepatic encephalopathy. The nurse determines that which noted serum laboratory abnormality supports this suspicion? 1.Protein level of 72 g/L (7.2 g/dL) 2.Ammonia level of 98 mcg/dL (60 mcmol/L) 3.Magnesium level of 1.7 mEq/L (0.85 mmol/L) 4.Total bilirubin level of 1.2 mg/dL (20.5 mcmol/L)
2
A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1.Select foods high in fat. 2.Increase intake of fluids, including juices. 3.Eat a good supper when anorexia is not as severe. 4.Eat less often, preferably only 3 large meals daily.
2
A client is experiencing blockage of the common bile duct. Which food selection made by the client indicates the need for further teaching? 1.Rice 2.Whole milk 3.Broiled fish 4.Baked chicken
2
A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? 1."I will obtain adequate rest." 2."I will take acetaminophen if I get a headache." 3."I should monitor my weight on a regular basis." 4."I need to include sufficient amounts of carbohydrates in my diet."
2
A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1."I should avoid drinking alcohol." 2."I can go back to work right away." 3."My partner should get the vaccine." 4."A condom should be used for sexual intercourse."
2
Aluminum hydroxide is prescribed for a client with chronic kidney disease (CKD). The nurse should instruct the client to take this medication at what time? 1.At bedtime 2.With meals 3.On an empty stomach 4.In the morning on arising
2
Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? 1.Vomiting occurs. 2.The fecal pH is acidic. 3.The client experiences diarrhea. 4.The client is able to tolerate a full diet.
2
The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note? 1.Weight loss 2.Peripheral edema 3.Capillary refill of 5 seconds 4.Bleeding from previous puncture sites
2
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1.Leukopenia with a shift to the left 2.Leukocytosis with a shift to the left 3.Leukopenia with a shift to the right 4.Leukocytosis with a shift to the right
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
The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value should the nurse expect to note? 1.Sodium level of 145 mEq/L (145 mmol/L) 2.Potassium level of 5.2 mEq/L (5.2 mmol/L) 3.Phosphorus level of 3.0 mg/dL (0.97 mmol/L) 4.Magnesium level of 1.3 mg/dL (0.53 mmol/L)
2
The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful? 1.Fresh fruit 2.Brown gravy 3.Fresh vegetables 4.Poultry without skin
2
The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1.Peritonitis 2.Hyperglycemia 3.Hyperphosphatemia 4.Disequilibrium syndrome
2
The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? 1.Restlessness 2.Presence of asterixis 3.Complaints of fatigue 4.Decreased serum ammonia levels
2
The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most likely to include which as a most common causative factor in this client's disorder? 1.Weight gain 2.Use of alcohol 3.Exposure to occupational chemicals 4.Abdominal pain relieved with food or antacids
2
The nurse is preparing to administer prescribed medications to a client with hepatic encephalopathy. The nurse anticipates that the primary health care provider's prescriptions will include which medication? 1.Bisacodyl 2.Lactulose 3.Magnesium hydroxide 4.Psyllium hydrophilic mucilloid
2
The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis? 1."I have had unprotected sex with multiple partners." 2."I ate shellfish about 2 weeks ago at a local restaurant." 3."I was an intravenous drug abuser in the past and shared needles." 4."I had a blood transfusion 30 years ago after major abdominal surgery."
2
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?
2-3 Ib
The nurse is caring for a client with acute pancreatitis. Which medications should the nurse expect to be prescribed for treatment of this problem? Select all that apply. 1.Insulin 2.Morphine 3.Dicyclomine 4.Pancrelipase 5.Pantoprazole 6.Acetazolamide
2356
The nurse is caring for a client at home with a T-tube secondary to liver and gallbladder cancer. Assessment includes temperature 100.2°F (37.8°C), heart rate 110 beats/minute, respirations 22 breaths/minute, blood pressure 110/76 mmHg, and pain 3 on a 1-10 scale. What should be the nurse's next action? 1. Ask the client when he last had something for pain. 2. Assess the T-tube color and amount. 3. Evaluate the insertion site of the T-tube. 4. Determine if the client has jaundice.
3
The nurse is caring for a client with acute glomerulonephritis. The nurse instructs the assistive personnel (AP) to implement which action when caring for the client? 1.Ambulate the client frequently. 2.Encourage a diet that is high in protein. 3.Remove the water pitcher from the bedside. 4.Monitor the client's temperature every 2 hours.
3
The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results? 1.Elevated level of pepsin 2.Decreased level of lactase 3.Elevated level of amylase 4.Decreased level of enterokinase
3
The nurse is completing a follow-up visit with an 8-yearold child with polycystic kidney disease. Which statement by the parent is most concerning? 1. "My son seems to drink a lot of water during the day." 2. "He doesn't seem to make friends very easily and would rather play alone." 3. "His new shoes I just bought last week are already too tight." 4. "My spouse is facing a job change, and we expect different insurance soon."
3
The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (CKD). Which factor will enhance the educational process?1.Anxiety 2.Memory deficits 3.Presence of family 4.Short attention span
3
The nurse is planning to make a home visit for a client with hepatitis C. What documentation should the nurse include in the chart concerning client/family teaching? 1. Family and client should not share eating utensils and dishes. 2. Eating utensils and dishes should be washed in hot water above 180°F. 3. Proper universal precautions should be observed when cleaning up blood from the client. 4. Family members should not come in contact with the client's medications.
3
The nurse is preparing to perform a discharge teaching with a client who is started on hemodialysis. Which information should the nurse provide regarding the hemodialysis schedule? 1. 5 hours of treatment, 2 days per week 2. 2 hours of treatment, 6 days per week 3. 3 to 4 hours of treatment, 3 days per week 4. 2 to 3 hours of treatment, 5 days per week
3
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? 1.Roast pork 2.Cheese omelet 3.Pasta with sauce 4.Tuna fish sandwich
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 nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1.Dorsiflex the client's foot. 2.Measure the abdominal girth. 3.Ask the client to extend the arms. 4.Instruct the client to lean forward.
3
The nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primary characteristics of the preicteric phase? 1.Pruritus 2.Right upper quadrant pain 3.Fatigue, anorexia, and nausea 4.Jaundice, dark-colored urine, and clay-colored stools
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
Which outcome should the nurse expect to observe in the client who is recovering from viral hepatitis without complications? 1.Presence of asterixis 2.Increasing prothrombin time values 3.Decrease in aspartate aminotransferase (AST) 4.Decreased absorption of vitamin K in the intestine
3
The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1.ST depression 2.Prominent U wave 3.Tall peaked T waves 4.Prolonged ST segment 5.Widened QRS complexes
3,5
A client with an arteriovenous fistula in the left arm who is undergoing hemodialysis is at risk for infection. Which should the nurse formulate as the best outcome goal for this client problem? 1.The client washes hands at least once per day. 2.The client's temperature remains lower than 101º F (38.3º C). 3.The client avoids blood pressure (BP) measurement in the left arm. 4.The client's white blood cell (WBC) count remains within normal limits.
4
A client with chronic kidney disease (CKD) has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse determines that these assessment data are compatible with which condition? 1.Advancing uremia 2.Phosphate overdose 3.Folic acid deficiency 4.Aluminum intoxication
4
The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1.Hypertension, tachycardia, and fever 2.Hypotension, bradycardia, and hypothermia 3.Restlessness, irritability, and generalized weakness 4.Headache, deteriorating level of consciousness, and twitching
4
The nurse has provided instructions regarding home care measures for a client with acute pyelonephritis. Which statement by the client indicates a need for further teaching?1."I should try to maintain an acid ash diet." 2."I should increase my fluid intake to 3 L per day." 3."I should take my daily dose of vitamin C to acidify the urine." 4."I need to avoid alcohol and highly spiced foods but may continue to drink my coffee every day."
4
The nurse is admitting a client who has an arteriovenous (AV) fistula in the right arm for hemodialysis. Which nursing intervention is the best way to prevent injury to the AV site?1.Putting a large note about the access site on the front of the medical record 2.Applying an allergy bracelet to the right arm, indicating the presence of the fistula 3.Telling the client to inform all caregivers who enter the room about the presence of the access site 4.Placing a sign at the bedside that reads "No blood pressure measurements or venipunctures in the right arm"
4
The nurse is analyzing the posthemodialysis 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
The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? 1.Milk 2.Chicken 3.Broccoli 4.Legumes
4
The nurse is caring for a client with possible cholelithiasis who is being prepared for intravenous cholangiography and is teaching the client about the procedure. Which statement indicates that the client understands the purpose of this test? 1."My gallbladder will be irrigated." 2."This procedure will drain my gallbladder." 3."They will put medication in my gallbladder." 4."They are going to look at my gallbladder
4
The nurse is caring for a client with suspected kidney failure. A 24-hour urine specimen is prescribed. What value measures overall kidney function? 1.Sodium levels 2.Protein levels 3.Blood uric acid levels 4.Creatinine clearance levels
4
The nurse is giving general instructions to a client receiving hemodialysis. Which statement would be most appropriate for the nurse to include? 1."It is acceptable to eat whatever you want on the day before hemodialysis." 2."It is acceptable to exceed the fluid restriction on the day before hemodialysis." 3."Medications should be double-dosed on the morning of hemodialysis because of potential loss." 4."Several types of medications should be withheld on the day of dialysis until after the procedure."
4
A client in end-stage renal failure has orders for sodium polystyrene sulfonate 15 grams PO in 90 mL. water 3 times daily. What would be the total daily dose of sodium polystyrene sulfonate?
45 grams in 270 mL
A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions should the nurse plan to promote client safety? Select all that apply. 1.Monitor serum potassium levels. 2.Weigh client daily, and monitor trends. 3.Monitor for symptoms of fluid retention. 4.Provide the client with a soft toothbrush. 5.Instruct the client to use an electric razor. 6.Monitor all secretions for frank or occult blood.
456
A client with a recently created vascular access for hemodialysis is being discharged. Which discharge teaching will the nurse include? A. Do not allow blood pressure measurements in the affected arm. B. Elevate the affected arm, allowing for total rest of the extremity. C. Assess for a bruit in the affected arm on a daily basis. D. Sleep on the affected side to protect the access device.
A
The nurse is caring for a 38-year-old male with hypertension and stage 1 CKD. The client reports lifestyle changes and feeling "better" and has stopped taking a prescribed diuretic. What is the appropriate nursing response? A. "The diuretic will reduce your blood pressure, which may slow or prevent progression of your chronic kidney disease." B. "Your primary health care provider prescribed the diuretic because it will reverse the damage caused by kidney disease." C. "Taking medications is a personal decision, and you have the right to decline this prescription." D. "Since you have implemented lifestyle changes, the diuretic is likely not needed."
A
The nurse is caring for a male client 8 hours after a nephrectomy. Which assessment data point requires immediate nursing intervention? A. Abdominal distention B. Urine output 38 mL in the last hour C. Blood pressure 108/64 mm Hg D. Hemoglobin 14 g/dL
A
The nurse is planning care for a client who had a laparoscopic Whipple surgery. For which complications will the nurse assess? Select all that apply. A. Bleeding B. Wound infection C. Intestinal obstruction D. Diabetes mellitus E. Abdominal abscess
A, B, C, D, E
Which assessment data would the nurse anticipate in a client with acute pyelonephritis? Select all that apply. A. Urinary frequency B. Dysuria C. Oliguria D. Heart rate 120 beats/min E. Uremia F. Costovertebral angle tenderness
A, B, D, F
When providing care to a client who has undergone a nephrostomy for hydronephrosis, which observation alerts the nurse to a possible complication? Select all that apply. A. Urine output of 15 mL for the first hour and then diminishing B. Tenderness at the surgical site C. Pink-tinged urine draining from the nephrostomy D. A hematocrit value 3% lower than the preoperative value E. Sudden onset of abdominal pain that worsens after abdominal palpation F. Blood pressure of 180/90 mm Hg that persists despite administration of pain medication
A, D, E, F
The nurse is caring for a client who is diagnosed with cirrhosis. Which serum laboratory value(s) will the nurse expect to be abnormal? Select all that apply. A. Prothrombin time B. Serum bilirubin C. Albumin D. Aspartate aminotransferase (AST) E. Lactate dehydrogenase (LDH) F. Acid phosphatase
A,B,C,D,E
A client was admitted to the hospital yesterday with a diagnosis of acute pancreatitis. What assessment findings will the nurse expect for this client? Select all that apply. A. Severe boring abdominal pain B. Jaundice C. Nausea and/or vomiting D. Decreased serum amylase level E. Leukocytosis F. Dyspnea
A,B,C,E,F
A client is receiving adefovir for management of hepatitis B. What health teaching will the nurse provide for the client about this drug? Select all that apply. A. "Avoid places with crowds and individuals who have infection." B. "Report increased bruising to your doctor because the drug can cause bleeding." C. "Get your lab work done regularly because the drug can affect your kidneys." D. "Be careful and avoid falls because the drug can cause fractures." E. "Follow up with the dietitian to ensure that you adhere to your special diet."
A,C
The nurse is caring for a client in end-stage liver failure. Which interventions should be implemented when observing for hepatic encephalopathy? Select all that apply. A. Assess the client's neurologic status as prescribed. B. Monitor the client's hemoglobin and hematocrit levels. C. Monitor the client's serum ammonia level. D. Monitor the client's electrolyte values daily. E. Prepare to insert an esophageal balloon tamponade tube. F. Make sure the client's fingernails are short.
A,C
The client is receiving ciprofloxacin 400 mg in 200 mL over 60 minutes IV every 12 hours for a catheterassociated urinary tract infection. The tubing drop factor is 10 gtts/mL. How many drops per minute will the nurse administer?_________ gtts/min
Answer: 33 gtts/min Rationale: 200 mL x 10 gtts = 2000 = 33 gtts/min 60 min mL 60
Which client will the nurse identify as at risk for acute kidney injury? Select all that apply. A. 68-year-old male with diabetes mellitus B. 16-year-old male football player in preseason practice C. 27-year-old female recovering from shock following a car accident D. 52-year-old male with newly diagnosed hypertension E. 30-year-old female in intensive care receiving multiple intravenous antibiotics
B,C,E
The nurse is caring for a 74-year-old client scheduled for a cardiac catheterization with contrast dye. What nursing action is appropriate? Select all that apply. A. Assess creatinine clearance using a 24-hour urine collection test. B. Assess for coexisting conditions of diabetes, heart failure, and kidney disease. C. Collaborate with the provider about whether IV fluids should be infused before the test. D. Notify the provider regarding changes in serum creatinine from 0.2 to 0.4 mg/dL in 24 hours. E. Alert the provider to a glomerular filtration rate (GFR) below 60 mL/min/1.73 m2.
B,C,E
The nurse is providing discharge teaching to a client recovering from kidney transplantation. Which client statement indicates understanding? A. "I can stop my medications when my kidney function returns to normal." B. "If my urine output decreases, I will increase my fluids." C. "The antirejection medications will be taken for life." D. "I will drink 8 ounces (236 mL) of water with my medications."
C
The nurse is caring for a client diagnosed with hepatitis A. Which transmission-based precautions are required when providing care for this client? Select all that apply. A. Place client in a private room. B. Wear a mask when handling patient bedpan. C. Wear gloves when touching the client. D. Wear a gown when providing personal care to this patient. E. Wear eye goggles when providing care.
C,D