Multisystem Care Exam #2
A client is scheduled to undergo kidney transplant surgery. Which teaching point does the nurse include in the preoperative teaching session? A. "It is essential for you to wash your hands and avoid people who are ill." B. "The new kidney will be placed directly below one of your old kidneys." C. "You will receive dialysis the day before surgery and for about a week after." D. "Your diseased kidney will be removed when the transplant is performed."
A. "It is essential for you to wash your hands and avoid people who are ill." Teaching the client to wash hands and stay away from sick people are important points for the nurse to include in teaching for a client scheduled for a kidney transplant. Antirejection medications increase the risks for infection, sepsis, and death. Strict aseptic technique and handwashing are essential. Unless severely infected, the client's kidneys are left in place and the graft is placed in the iliac fossa. Dialysis is performed the day before surgery. After the surgery, the new kidney should begin to make urine.
The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse? A. "These interventions help to reduce the ammonia level." B. "These interventions help to prevent heart failure." C. "These interventions help the client's jaundice improve." D. "These interventions help to prevent nausea and vomiting."
A. "These interventions help to reduce the ammonia level." The client's high ammonia level has caused encephalopathy which can become so severe that it causes death. These interventions help to reduce ammonia in the body so that this condition does not worsen.
The nurse is caring for client who is receiving erythropoietin. Which assessment finding indicates a positive response to the medication? A. A decrease in fatigue B. Potassium within normal range C. Absence of spontaneous fractures D. Hematocrit of 26.7%
A. A decrease in fatigue The assessment finding of less fatigue is considered a positive response to erythropoietin. Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue. A hematocrit value of 26.7% is low. Erythropoietin would restore the hematocrit to at least 36% to be effective. Erythropoietin stimulates the bone marrow to increase red blood cell production and maturation, increasing H&H, not potassium. Calcium supplements and phosphate binders prevent renal osteodystrophy and do not treat anemia.
A patient taking Tapazole (thiamazole) reports feeling dizzy, intolerant to cold, and tired. On assessment, you note the patient's heart rate is 45 and blood pressure is 70/30. What is the most likely cause? A. Antithyroid toxicity B. Agranulocytosis C. Thyroid storm D. Bronchospasm
A. Antithyroid toxicity The patient may be experiencing antithyroid toxicity (too much of the antithyroid medication). This will causes signs and symptoms of hypothyroidism which can lead to a myxedema coma, if not treated immediate
Which client will the nurse assess as at risk for acute kidney injury (AKI)? (Select all that apply.) A. Client in the intensive care unit on high doses of antibiotics B. Football player in preseason practice C. Accident victim recovering from a severe hemorrhage D. Accountant with poorly controlled diabetes mellitus E. Client who underwent contrast dye radiology F. Client recovering from gastrointestinal influenza
A. Client in the intensive care unit on high doses of antibiotics B. Football player in preseason practice C. Accident victim recovering from a severe hemorrhage E. Client who underwent contrast dye radiology F. Client recovering from gastrointestinal influenza To prevent AKI, all people must be urged to avoid dehydration by drinking at least 2 to 3 L of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Poorly controlled diabetes mellitus is a risk factor for chronic kidney disease.
The nurse is caring for a client following a kidney transplant. Which assessment data indicate to the nurse possible rejection of the kidney? (Select all that apply.) A. Crackles in the lung fields B. Temperature of 98.8° F (37.1° C) C. Blood pressure of 164/98 mm Hg D. Blood urea nitrogen (BUN) 21 mg/dL (7.5 mmol/L), creatinine 0.9 mg/dL (80 mcmol/L) E. 3+ edema of the lower extremities
A. Crackles in the lung fields C. Blood pressure of 164/98 mm Hg E. 3+ edema of the lower extremities Signs and symptoms indicating rejection of a transplanted kidney include: crackles in the lung fields, blood pressure of 164/78 mm Hg, and 3+ edema of lower extremities. These are assessment findings related to fluid retention and transplant rejection. Increasing BUN and creatinine are symptoms of rejection; however, a BUN of 21 mg/dL (7.5 mmol/L) and a creatinine of 0.9 mg/dL (80 mcmol/L) reflect normal values. Fever, not normothermia, is symptomatic of transplant rejection.
A client with end-stage kidney disease has been placed on fluid restrictions. Which assessment data indicates to the nurse that the fluid restriction has not been followed? A. Dyspnea and anxiety at rest B. Blood pressure of 118/78 mm Hg C. Central venous pressure (CVP) of 6 mm Hg D. Weight loss of 3 lb (1.4 kg) during hospitalization
A. Dyspnea and anxiety at rest The assessment finding that shows that the client has not adhered to fluid restriction is dyspnea and anxiety at rest. Dyspnea is a sign of fluid overload and possible pulmonary edema. The nurse needs to assist the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures. 118/78 mm Hg is a normal blood pressure. Excess fluid intake and fluid retention are manifested by an elevated CVP (>8 mm Hg) and weight gain, not weight loss.
When assisting with dietary protein needs for a client on peritoneal dialysis, the nurse recommends which food selection? A. Eggs B. Ham C. Eggplant D. Macaroni
A. Eggs The nurse recommends eggs as a dietary protein need for a client on peritoneal dialysis. Other suggested protein-containing foods for this client are milk and meat. Although a protein, ham is high in sodium and needs to be avoided. Vegetables and pasta contain mostly carbohydrates. Peritoneal dialysis clients are allowed 1.2 to 1.5 g of protein/kg/day because protein is lost with each exchange.
When caring for a client with a left forearm arteriovenous fistula created for hemodialysis, which nursing actions are required? (Select all that apply.) A. Ensure that no blood pressures are taken in that arm. B. Teach the client to palpate for a thrill over the site. C. Elevate the arm above heart level. D. Auscultate for a bruit every 8 hours. E. Check brachial pulses daily.
A. Ensure that no blood pressures are taken in that arm. B. Teach the client to palpate for a thrill over the site. D. Auscultate for a bruit every 8 hours. A bruit or swishing sound and a thrill or buzzing sensation upon palpation would be present in this client, indicating patency of the fistula. No blood pressure, venipuncture, or compression, such as lying on the fistula, would occur. Distal pulses and capillary refill would be checked daily. For a forearm fistula, the radial pulse is checked instead of the brachial pulse which is proximal. Elevating the arm increases venous return, possibly collapsing the fistula.
When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) A. Esophageal varices B. Ascites C. Hematuria D. Hemorrhoids E. Fever
A. Esophageal varices B. Ascites D. Hemorrhoids Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.
The nurse is caring for a client who has been diagnosed with cirrhosis. Which laboratory result(s) would the nurse expect for this client? (Select all that apply.) A. Increased serum bilirubin B. Increased lactate dehydrogenase C. Decreased serum albumin D. Increased serum alanine aminotransferase E. Increased aspartate aminotransferase F. Increased serum ammonia
A. Increased serum bilirubin B. Increased lactate dehydrogenase C. Decreased serum albumin D. Increased serum alanine aminotransferase E. Increased aspartate aminotransferase F. Increased serum ammonia Cirrhosis is a chronic disease in which the liver progressively degenerates. As a result, liver enzymes and bilirubin increase. Additionally, the liver is unable to synthesize protein leading to decreased serum albumin. Elevated serum ammonia results from the inability of the liver to detoxify protein by-products.
When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.) A. Right upper quadrant tenderness B. Itching C. Recent influenza infection D. Brown stool E. Tea-colored urine
A. Right upper quadrant tenderness B. Itching E. Tea-colored urine Assessment findings the nurse expects to find in a client with hepatitis B include brown, tea-, or cola-colored urine; right upper quadrant pain due to inflammation of the liver; and itching, irritating skin caused by deposits of bilirubin on the skin secondary to high bilirubin levels and jaundice. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored, not typically brown.
Which of the following foods below should a patient experiencing a thyroid storm avoid? (Select all that apply). A. Shrimp B. Milk C. Hard boiled eggs D. Seaweed (Kelp) E. Broccoli F. Peas
A. Shrimp B. Milk C. Hard boiled eggs D. Seaweed (Kelp) Foods high in iodine are seafoods like shrimp, seaweed, and dairy/eggs.
When caring for a client who receives peritoneal dialysis (PD), which finding does the nurse report to the provider (HCP) immediately? A. Temperature of 101.2° F (38.4° C) B. Sinus bradycardia, rate of 58 beats/min C. Pulse oximetry reading of 95% D. Blood pressure of 148/90 mm Hg
A. Temperature of 101.2° F (38.4° C) The nurse needs to immediately report a peritoneal dialysis client's temperature of 101.2° F (38.4° C) to the HCP. Peritonitis is the major complication of PD, caused by intra-abdominal catheter site contamination. Meticulous aseptic technique must be used when caring for PD equipment. A pulse oximetry reading of 95% is a normal saturation. Although a heart rate of 58 beats/min is slightly bradycardic, the HCP can be informed upon visiting the client. Clients with kidney failure tend to have slightly higher blood pressures due to fluid retention. This is not as serious as a fever.
Which statement made by the client alerts the nurse to the possibility of hypothyroidism? A. "I seem to feel the heat more than other people." B. "I am always tired, even when I get 10 or 12 hours of sleep." C. "Food just doesn't taste good without a lot of salt." D. "My grandmother had thyroid problems."
B. "I am always tired, even when I get 10 or 12 hours of sleep." Clients with hypothyroidism usually feel tired or weak and often report an increase in time spent sleeping, sometimes up to 14 to 16 hours per day. Thyroid problems are very common among women and do not demonstrate a specific pattern of inheritance. Clients with hypothyroidism have a slow metabolism and have difficulty keeping warm. Salt craving is not a symptom of hypothyroidism.
Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. "The scars on my liver create problems with blood circulation." B. "My liver is scarred, but the cells can regenerate themselves and repair the damage." C. "Because of the scars on my liver, blood clotting and blood pressure are affected." D. "Cirrhosis is a chronic disease that has scarred my liver."
B. "My liver is scarred, but the cells can regenerate themselves and repair the damage." The client's statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage.
Which patient is most at risk for Thyroid Storm? A. A 60 year old female who reports not taking Synthroid regularly. B. A 45 year old male who has not been taking Tapazole as ordered and is experiencing diabetic ketoacidosis. C. A 6 year old with an allergy to iodine. D. A 25 year old female who is pregnant with her 4th child and is experiencing eczema.
B. A 45 year old male who has not been taking Tapazole as ordered and is experiencing diabetic ketoacidosis. The red flag in this option is "not been taking Tapazole" and is experiencing "DKA". This indicates the patient has hyperthyroidism (Tapazole is an antithyroid medication) and this already puts him at risk for thyroid storm. Then DKA is another added stress on the body that can send him into thyroid storm. All the other options are either incorrect or the patient is at risk for myxedema coma (a complication of HYPOTHYROIDISM).
Which of the following medication orders should a nurse question if ordered on a patient with thyroid storm? A. Propylthiouracil "PTU" for a 25 year old who is 8 weeks pregnant B. Aspirin as needed for a fever greater than 102.2 'F C. Inderal (propranolol) for a patient who reports having insomnia D. Tapazole (thiamazole) for a 30 year old having complaints of a headache
B. Aspirin as needed for a fever greater than 102.2 'F A patient who has hyperthyroidism or thyroid storm should NEVER take salicylate (ex: aspirin) because it can increase thyroid hormones. All the other options are correct or insignificant for why the patient is taking the medication.
A client with a recently created vascular access for hemodialysis is being discharged. Which teaching will the nurse include in the discharge instructions? A. How to practice proper nutrition? B. Avoiding venipuncture and blood pressure measurements in the affected arm C. How to assess for a bruit in the affected arm? D. Modifications to allow for complete rest of the affected arm
B. Avoiding venipuncture and blood pressure measurements in the affected arm The nurse must teach the client to avoid venipunctures and blood pressure measures in the arm that contains the newly created vascular access device. Compression of vascular access causes decreased blood flow and may cause occlusion. If this occurs, lifesaving dialysis will not be possible. The arm with the access device must be exercised to encourage venous dilation, not rested. The client can palpate for a thrill, but a stethoscope is needed to auscultate the bruit at home. The nurse needs to take every opportunity to discuss nutrition, even as it relates to wound healing, but loss of the venous access device must take priority.
To prevent prerenal acute kidney injury, which person will the nurse encourage to increase fluid consumption? A. Office secretary B. Construction worker C. School teacher D. Taxicab driver
B. Construction worker Construction workers perform physical labor and work outdoors, especially in warm weather. Working in this type of atmosphere causes diaphoresis and places this worker at risk for dehydration and prerenal azotemia. The office secretary and schoolteacher work indoors and, even without air conditioning, will not lose as much fluid to diaphoresis as someone performing physical labor. The taxicab driver, even without air conditioning, will not experience diaphoresis and fluid loss like the construction worker.
The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective? A. Increased blood pressure B. Decreased weight C. Increased pulse D. Decreased pain
B. Decreased weight A paracentesis is performed to remove ascitic fluid from the abdomen. Therefore, the client should weigh less after the procedure than before. Blood pressure should decrease due to less fluid volume and the pulse rate may not be affected. The client may report less abdominal discomfort or ease in breathing, but pain is not a common problem for cirrhotic clients.
While managing care for a client with chronic kidney disease, which action does the registered nurse (RN) plan to delegate to assistive personnel (AP)? (Select all that apply.) A. Explain the components of a low-sodium diet. B. Document the amount the client drinks throughout the shift. C. Auscultate the client's lung sounds every 4 hours. D. Check the arteriovenous (AV) fistula for a thrill and bruit. E. Obtain the client's prehemodialysis weight.
B. Document the amount the client drinks throughout the shift. E. Obtain the client's prehemodialysis weight. Actions the RN delegates to the UAP include: obtaining the client's weight and documenting oral fluid intake. These are routine tasks that can be performed by a UAP. Assessment skills (checking the AV fistula and auscultating lung sounds) and client education (explaining special diet) require more education and are in the legal scope of practice of the RN.
The nurse is assessing a client who is diagnosed as having Hepatitis A and asks how someone gets this disease. What is the most likely cause of the client's Hepatitis A? A. Being exposed to blood or blood products B. Eating contaminated food or water C. Having unprotected sex D. Sharing needles for illicit drugs
B. Eating contaminated food or water Hepatitis A is transmitted through the fecal-oral route rather than via blood. Therefore, contaminated food or water with Escherichia coli or other microbes can cause this liver infection.
A client is receiving immune-suppressive therapy after kidney transplantation. Which measure for infection control is important for the nurse to implement? A. Adherence to therapy B. Handwashing C. Monitoring for low-grade fever D. Strict clean technique
B. Handwashing Handwashing is the most important infection control measure for the client receiving immune-suppressive therapy to perform. Adherence to therapy and monitoring for low-grade fever are important but are not infection control measures. The nurse must practice aseptic technique for this client, not simply clean technique.
A physician orders a patient in thyroid storm to be started on Inderal (propranolol). What in the patient's health history causes the nurse to question the doctor's order? A. History of mental illness B. History of asthma C. History of tachycardia D. History of cancer
B. History of asthma Patients with a history of asthma should not take Inderal (a beta blocker) because it can cause asthma exacerbation or bronchospasm. Therefore, the nurse should question this order.
The nurse teaches a client who is recovering from acute kidney injury to avoid which type of medication? A. Opioids B. Nonsteroidal anti-inflammatory drugs (NSAIDs) C. Calcium channel blockers D. Angiotensin-converting enzyme (ACE) inhibitors
B. Nonsteroidal anti-inflammatory drugs (NSAIDs) Clients recovering from acute kidney disease need to be taught to avoid NSAIDs. NSAIDs may be nephrotoxic to a client with acute kidney disease and must be avoided. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opioids may be used by clients with kidney disease if severe pain is present. Excretion, however, may be delayed. Calcium channel blockers can improve the glomerular filtration rate and blood flow within the kidney.
Nurse Oliver should expect a client with hypothyroidism to report which health concerns? A. Increased appetite and weight loss B. Puffiness of the face and hands C. Nervousness and tremors D. Thyroid gland swelling
B. Puffiness of the face and hands Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).
When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? (Select all that apply.) A. Elevated magnesium B. Swollen abdomen C. Prolonged partial thromboplastin time D. Elevated amylase level E. Currant jelly stool F. Icterus of skin
B. Swollen abdomen C. Prolonged partial thromboplastin time F. Icterus of skin Clients with Laennec cirrhosis have damaged clotting factors, so prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity. Elevated magnesium is not related to cirrhosis. Amylase is typically elevated in pancreatitis. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. It is also consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase.
Which of the following are not a treatment for Thyroid Storm? A. Propylthiouracil (PTU) B. Synthroid (levothyroxine) C. Inderal (propranolol) D. Glucocorticoids
B. Synthroid (levothyroxine) Synthroid is a medication treatment for HYPOthyroidism. All the other options are for HYPERthyroidism.
The nurse is caring for a client with acute kidney injury and a temporary subclavian hemodialysis catheter. Which assessment finding requires nursing action? A. Mild discomfort at the insertion site B. Temperature 100.8° F (38.2° °C) C. Anorexia D. 1+ ankle edema
B. Temperature 100.8° F (38.2° °C) In this client situation, the nurse reports an assessment finding of a temperature of 100.8° F (38.2° C) to the HCP. Infection is a major complication of temporary catheters. All symptoms of infection, including fever, must be reported to the provider because the catheter may have to be removed. Mild discomfort at the insertion site is expected with a subclavian hemodialysis catheter. During acute injury, oliguria with resulting fluid retention and 1+ ankle edema is expected. Rising blood urea nitrogen may result in anorexia, nausea, and vomiting.
Which of the following assessment findings characterize thyroid storm? A. increased body temperature, decreased pulse, and increased blood pressure B. increased body temperature, increased pulse, and increased blood pressure C. increased body temperature, decreased pulse, and decreased blood pressure D. increased body temperature, increased pulse, and decreased blood pressure
B. increased body temperature, increased pulse, and increased blood pressure Thyroid storm is characterized by SNS activation. Thyroid hormones potentiate effects of catecholamines (epinephrine/norepinephrine). Therefore, all vital signs will be increased.
Which precaution will the nurse include when providing instructions to the female client with hypothyroidism who is prescribed to take thyroid hormone replacement therapy (HRT)? A. "Increase the amount of fiber in your diet to prevent the side effect of constipation." B. "Stop this drug immediately if you discover you are pregnant." C. "Avoid over-the-counter medications unless prescribed by your primary health care provider." D. "If you miss a dose, double your next day's dose."
C. "Avoid over-the-counter medications unless prescribed by your primary health care provider." The amount of drug in synthetic thyroid hormone tablets is very small and many other foods and drugs interfere with its absorption. The client is instructed to not take over-the-counter medications without approval from the primary health care provider. Fiber greatly interferes with the drug's absorption and is not to be taken with or within 4 hours of HRT. In addition, the drug does not cause constipation. Thyroid HRT must continue during pregnancy. The therapy works best when blood levels are maintained. The client is taught to take the forgotten drug as soon as it is remembered and not to double the next day's dose.
Which action by the nurse would most likely help to relieve symptoms associated with ascites? A. Monitoring serum albumin levels B. Lowering the head of the bed C. Administering oxygen therapy D. Administering intravenous fluids
C. Administering oxygen therapy The best action by the nurse caring for a client with ascites is to elevate the head of the bed and provide supplemental oxygen. The enlarged abdomen of ascites limits respiratory excursion. Fowler position will increase excursion and reduce shortness of breath. Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.
A client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? A. Monitor for decreased peripheral pulses. B. Determine if the client is able to ambulate. C. Auscultate for pericardial friction rub. D. Assess for crackles.
C. Auscultate for pericardial friction rub. The additional assessment needed for the client with uremia is to auscultate the pericardium for friction rub. Clients with CKD are prone to pericarditis. Signs/symptoms of pericarditis include inspiratory chest pain, tachycardia, narrow pulse pressure, low-grade fever, and pericardial friction rub. Crackles and tachycardia are symptomatic of fluid overload. Fever is not present with fluid overload. Although the nurse will monitor pulses, and ambulation is important to prevent weakness and deep vein thrombosis, these are not pertinent to the constellation of signs/symptoms of pericarditis that the client presents with.
The nurse is caring for a client with kidney failure. Which assessment data indicates the need for increased fluids? A. Decreased sodium level B. Pale-colored urine C. Increased blood urea nitrogen (BUN) D. Increased creatinine level
C. Increased blood urea nitrogen (BUN) An increase in BUN can be an indication of dehydration, and a needed increase in fluids. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted and does not indicate that an increase in fluids is necessary. Sodium is increased, not decreased, with dehydration.
What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A. Drink only bottled water and avoid ice. B. Avoid sharing the bathroom with the client. C. Members of the household must not share toothbrushes. D. The client must not consume alcohol.
C. Members of the household must not share toothbrushes. The nurse teaches the family of a client with hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water needs to be avoided.
When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? A. Clients who work with shellfish. B. Clients with elevations of aspartate aminotransferase and alanine aminotransferase. C. Men who engage in sex with men. D. Clients traveling to a third-world country.
C. Men who engage in sex with men. Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A. Hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.
An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of: A. Thyroid storm. B. Cretinism. C. Myxedema coma. D. Hashimoto's thyroiditis.
C. Myxedema coma. Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.
Which assessment is a priority for the nurse to make when a client with diabetic ketoacidosis (DKA) who is being monitored while receiving an insulin infusion begins to show an irregular heart beat with inverted T-waves? A. Rate of IV infusion B. Urine output C. Potassium level D. Breath sounds
C. Potassium level After DKA therapy starts, serum potassium levels drop quickly. An ECG showing an irregular pattern and inverted T-waves is most likely related to low potassium levels (hypokalemia). Hypokalemia is a common cause of death in the treatment of DKA. Detecting and treating the underlying cause of the cardiac irregularities is essential. The cardiac issues are not associated with changes in urine output even though hyperglycemia will cause osmotic diuresis. The client with DKA is not at risk for hypoventilation or poor gas exchange. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the hypokalemia.
The nurse is teaching dietary modification to a client with acute kidney injury (AKI). What dietary teaching will the nurse include? (Select all that apply.) A. Liberal sodium B. Low fat C. Restricted fluids D. Restricted protein E. Low potassium
C. Restricted fluids D. Restricted protein E. Low potassium A client with acute kidney injury needs to modify the diet to include restricted protein, restricted fluids, and low potassium. Breakdown of protein leads to azotemia and increased blood urea nitrogen. For the client who does not require dialysis, 0.6 g/kg of body weight or 40 g/day of protein is usually prescribed. For clients who do require dialysis, the protein level needed will range from 1 to 1.5 g/kg. Fluid is restricted during the oliguric stage. The daily amount of fluid permitted is calculated to be equal to the urine volume plus 500 mL. Potassium intoxication may occur, so dietary potassium is also restricted. Dietary potassium is restricted to 60 to 70 mEq/kg (70 mmol/kg).Sodium is restricted during AKI because oliguria causes fluid retention. Dietary sodium recommendations range from 60 to 90 mEq/kg (60 to 90 mmol/kg). Fats may be used for needed calories when proteins are restricted.
A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug effect? A. Dysuria B. Leg cramps C. Tachycardia D. Blurred vision
C. Tachycardia Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent include tachycardia. The other options aren't associated with levothyroxine.
The nurse is caring for a client who has cirrhosis of the liver. The client's latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor: A. deep vein thrombosis. B. jaundice. C. hematemesis. D. pressure injury.
C. hematemesis. The client who has cirrhosis is at risk for bleeding due to decreased production of prothrombin by the liver. Portal hypertension that occurs in clients with cirrhosis causes esophageal blood veins to become fragile, distended, and tortuous. Therefore, these veins tend to bleed as evidenced by either hematemesis or melena.
Discharge teaching has been provided for a client recovering from kidney transplantation. Which client statement indicates understanding of the teaching? A. "I will drink 8 ounces (236 mL) of water with my medications." B. "I can stop my medications when my kidney function returns to normal." C. "If my urine output is decreased, I should increase my fluids." D. "The antirejection medications will be taken for life."
D. "The antirejection medications will be taken for life." When the client states that antirejection medications must be taken for life, it indicates that the kidney transplant client understands the discharge teaching. Immune-suppressant therapy must be taken for life to prevent organ rejection. Adherence to immunosuppressive drugs is crucial to survival for clients with transplanted kidneys. Lack of adherence can lead to complications such as rejection, graft loss, return to dialysis, and death. Oliguria (decreased urine output) is a symptom of transplant rejection. If this occurs, the transplant team must be contacted immediately. It is not necessary to take antirejection medication with 8 ounces (236 mL) of water.
A client is being treated for kidney failure. Which nursing statement encourages the client to express his or her feelings? A. "All of this is new. What can't you do?" B. "How are you doing this morning?" C. "Are you afraid of dying?" D. "What concerns do you have about your kidney disease?"
D. "What concerns do you have about your kidney disease?" Asking the client about any concerns regarding your disease is an open-ended statement and specific to the client's concerns. Asking the client to explain what he or she can't do implies inadequacy on the client's part. Asking the client if he or she is afraid of dying is too direct and would likely cause the client to be anxious. Asking the client how he or she is doing is too general and does not encourage the client to share thoughts on a specific topic.
Which action is most important for the nurse to take first after finding a client who has severe hypothyroidism to be unresponsive to attempts to waken her and have a heart rate of 46 beats/min? A. Increasing the IV infusion rate B. Initiating the Rapid Response Team C. Assessing temperature D. Applying oxygen by mask
D. Applying oxygen by mask The most common cause of death with severe hypothyroidism is respiratory failure with decreased gas exchange. The nurse would apply oxygen first and then initiate the Rapid Response Team. Although a decreased body temperature would support the findings that a client with severe hypothyroidism is worsening, assessing it would not be helpful in this situation. Increasing the IV flow rate may not even improve cardiac output because the slow heart rate is not related to a volume deficit but to reduced myocardial contractility.
When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? A. Assist the provider to insert a trocar catheter into the abdomen. B. Position the client with the head of the bed flat. C. Encourage the client to take deep breaths and cough. D. Ask the client to void prior to the procedure.
D. Ask the client to void prior to the procedure. To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure. Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder.
The RN has just received change-of-shift report. Which client will the nurse assess first? A. Client with azotemia whose blood urea nitrogen and creatinine are increasing. B. Client with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted. C. Client receiving peritoneal dialysis who needs help changing the dialysate bag. D. Client with chronic kidney failure who was just admitted with shortness of breath.
D. Client with chronic kidney failure who was just admitted with shortness of breath. After the change-of-shift report, the nurse must first assess the newly admitted client with chronic kidney failure and shortness of breath, the dyspnea of the client with chronic kidney failure may indicate pulmonary edema and must be assessed immediately. The client with kidney insufficiency is stable and assessment can be performed later. The client with azotemia requires assessment and possible interventions but is not at immediate risk for life-threatening problems. The client receiving peritoneal dialysis can be seen last because it is a slow process and the client has no urgent needs.
The nurse is caring for a client who was recently diagnosed with Laennec cirrhosis. What is the nurse's priority assessment during client care? A. Cardiovascular assessment B. Abdominal assessment, including bowel sounds C. Respiratory assessment D. Cognitive and neurologic assessment
D. Cognitive and neurologic assessment The type of cirrhosis that this client has is caused by alcoholism. Withdrawal from alcohol can cause cognitive and neurologic changes, such as confusion and delirium tremens (DTs).
Which factor or condition does the nurse expect to result in an increase in a client's production of thyroid hormones (TH)? A. Getting 8 hours of sleep nightly B. Chronic constipation C. Protein-calorie malnutrition D. Cold environmental temperatures
D. Cold environmental temperatures Cold and stress are two factors that cause the hypothalamus to secrete thyrotropin-releasing hormone (TRH), which then stimulates the anterior pituitary to secrete thyroid-stimulating hormone (TSH) to increase production of the two major thyroid hormones. Constipation does not affect thyroid hormone production. Stress from inadequate sleep could increase TH production but adequate sleep does not. Protein-calorie malnutrition would decrease production of many hormones, including TH.
For which new-onset symptom or behavior will the nurse teach a client taking thyroid hormone replacement therapy (HRT) to report immediately to the primary health care provider? A. Calf muscle cramping B. Runny nose C. Anorexia D. Hand tremors
D. Hand tremors Hand tremors are an indication of HRT toxicity with increased central nervous system stimulation. The dose must be decreased to prevent more serious neurologic and cardiac toxicities. Anorexia, runny nose, and muscle cramping are neither side effects of the drug nor indications of toxicity.
A patient is admitted with thyroid storm. Which sign and symptoms are NOT present with this condition? (Select all that apply). A. Temperature of 104.9'F B. Heart rate of 125 bpm C. Respirations of 42 D. Heart rate of 20 bpm E. Intolerance to cold F. Restless
D. Heart rate of 20 bpm E. Intolerance to cold Bradycardia (heart rate of 20 bpm) and intolerance to cold are NOT signs and symptoms of thyroid storm. All the other options are very typical signs and symptoms of thyroid storm.
The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor? A. Acute kidney injury B. Hypertension C. Pulmonary edema D. Infection
D. Infection The client is at the most risk for rejection of the transplant which can be the result of an infection if not identified and managed effectively. Therefore, the nurse would teach the client and family to report cough, fever, skin redness, and other signs of infection.
Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? A. Administering morphine for pain B. Assessing the wound dressing for bleeding C. Hyperextending the neck D. Monitoring oxygen saturation
D. Monitoring oxygen saturation Airway assessment and management is always the first priority with every client, especially for a client who has had surgery that involves potential bleeding and edema near the trachea. Assessing the wound dressing for bleeding is a high priority, which is performed next after assessing airway and breathing. Pain control is important, but can be addressed after airway assessment. The neck should not be extended or hyperextended because this position puts too much tension on the incision.
A client admitted to the medical unit with a history of vomiting and diarrhea and an increased blood urea nitrogen requires 1 L of normal saline infused over 2 hours. Which staff member would be assigned to care for the client? A. LPN/LVN with experience working on the medical unit. B. New graduate RN who just finished a 6-week orientation. C. RN who has floated from pediatrics for this shift. D. RN who usually works on the general surgical unit.
D. RN who usually works on the general surgical unit. The RN who usually works on the general surgical unit would have the most experience in taking care of surgical clients and would be most capable of monitoring the client receiving rapid fluid infusions. This client is at risk for complications such as pulmonary edema and acute kidney failure. The pediatric float RN and the new graduate RN will have less experience in caring for this type of client. The LPN/LVN would not be assigned to a client requiring IV therapy and who is at high risk for complications.
How would the home care nurse best modify the client's home environment to manage side effects of lactulose? A. Obtains a walker for the client. B. Rearranges furniture to declutter the home. C. Removes throw rugs to prevent falls. D. Requests a bedside commode for the client.
D. Requests a bedside commode for the client. The home care nurse would modify the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet.
Which changing trends in a client's serum laboratory values indicate to the nurse that thyroid hormone replacement therapy for hypothyroidism is effective? A. Declining thyroglobulin (Tg) levels; rising thyrotropin receptor antibody (TRAb) levels B. Declining thyroid hormone (TH) levels; rising thyroid-stimulating hormone (TSH) levels C. Rising thyroglobulin (Tg) levels; declining thyrotropin receptor antibody (TRAb) levels D. Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels
D. Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels Drug therapy for hypothyroidism hormone replacement therapy with synthetic thyroid hormones, which would result in rising TH levels. As these levels rise, the negative feedback loop, which tries to stimulate the thyroid gland to produce TH would be suppressed, causes declining TSH levels. Thyroglobulin levels are related to active thyroid tissue. In hypothyroidism, these levels are low and drug therapy does not increase them. TRAbs are not a cause of hypothyroidism and do not develop with drug therapy.
The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching? A. Calcium B. Potassium C. Magnesium D. Sodium
D. Sodium Mild to moderate sodium restriction is often tried as the first intervention to decrease body fluid retention, including ascites.
While assisting a client during peritoneal dialysis, the nurse observes the drainage stop after 200 mL of peritoneal effluent drains into the bag. What action will the nurse implement? A. Document the effluent as output. B. Instruct the client to cough. C. Reposition the catheter. D. Turn the client to the opposite side.
D. Turn the client to the opposite side. The nurse's first action in this situation is to turn the client to the opposite side. With peritoneal dialysis, usually 1 to 2 L of dialysate is infused by gravity into the peritoneal space. The fluid dwells in the peritoneal cavity for a specified time, then drains by gravity into a drainage bag. The peritoneal effluent or outflow generally is a continuous stream after the clamp is completely open. Potential causes of flow difficulty include constipation, kinked or clamped connection tubing, the client's position, fibrin clot formation, and catheter displacement. If inflow or outflow drainage is inadequate, reposition the client to stimulate inflow or outflow. Turning the client to the other side or ensuring that he or she is in good body alignment may help. Instructing the client to cough will not promote dialysate drainage. Increased abdominal pressure from coughing contributes to leakage at the catheter site. The nurse needs to measure and record the total amount of outflow after each exchange. However, the nurse needs to reposition the client first to assist with complete dialysate drainage. An x-ray is needed to identify peritoneal dialysis catheter placement. Only the health care provider repositions a displaced catheter.