NUR425:Exam2:Q/A
The nurse is providing care to a patient who requires the removal of a kidney stone. Which procedure does the nurse anticipate will be ordered for this patient?
A cystoscope is inserted into the urethra and guided into the bladder, allowing healthcare providers to visually examine the bladder and bladder, potentially performing interventions like kidney stone removal.
In reviewing a patient's complete blood count (CBC) results, the nurse notes a "shift to the left." What is the significance of these results?
A "shift to the left" in a blood test means there are more immature neutrophils (band cells) present. It suggests an infection or inflammation, indicating the body's response. Monitoring it helps guide treatment decisions.
A patient in sickle cell crisis reports taking a recent skiing trip that caused a respiratory infection from the cold weather. Which nursing diagnosis is a priority for this patient?
A patient with a sickle cell crisis after a skiing trip causes acute pain due to blockage in blood flow and oxygen delivery. Prioritizing pain management is crucial for improving well-being and daily activities.
A patient complaining of mouth soreness had gastric bypass surgery 1 year ago. During the assessment, the nurse notes the patient's tongue is beefy, red, and smooth and the patient's skin appears yellowish. The nurse correlates these findings to a decreased value of which diagnostic test?
A year ago, a patient with gastric bypass surgery experienced mouth soreness, red tongue, and yellowish skin. Vitamin B12 deficiency may cause symptoms, and a diagnostic test can confirm the issue.
The nurse monitors for which clinical manifestations in the patient diagnosed with acute glomerulonephritis? Select all that apply.
Acute glomerulonephritis patients may experience hematuria, proteinuria, serum BUN 8.0 mg/dL, elevated creatinine 2.4 mg/dL, and increased urine output. These symptoms indicate impaired kidney function and increased urine output, potentially causing polyuria.
In completing a physical assessment in an 80-year old male, the nurse correlates which findings to age-related changes to the hematological system? Select all that apply.
Age-related hematological changes in an 80-year-old male can lower iron binding and ESR. Aging causes these changes. Elevated B and T lymphocytes, hemoglobin, and hematocrit are not usually associated with age-related changes and may require further investigation.
In monitoring a patient's renal function, the nurse recognizes that aldosterone is released in response to which physiological factor?
Aldosterone, a hormone produced by adrenal glands, is released when blood pressure drops or volume decreases. Regulated by the renin-angiotensin-aldosterone system (RAAS), it increases sodium reabsorption and potassium excretion, regulating blood pressure and fluid balance.
In monitoring a patient at the completion of a bleeding time test, which finding requires an intervention?
An intervention is necessary if bleeding persists beyond 5 minutes after a bleeding time test, indicating abnormal bleeding clotting or platelet dysfunction. Immediate medical intervention is needed to prevent excessive bleeding or complications.
A patient diagnosed with aplastic anemia is admitted to the hospital. In teaching the patient and family about this disease process, what information does the nurse include?
Aplastic anemia is when bone marrow doesn't produce enough blood cells, affecting red, white, and platelets. Stem cell damage can cause it, not always by viruses. Causes: Chemicals, radiation therapy, or autoimmune reactions.
In monitoring a patient's renal function, the nurse recognizes that antidiuretic hormone (ADH) is released in response to which physiological factor? Select all that apply.
Based on serum osmolality and salt content, nurses detect ADH release to assess renal function. High osmolality conserves water, while high salt levels reabsorb water and limit urine production. 148 mEq/L sodium and 310 mOsm/L osmolality are correct.
What laboratory values does the nurse need to assess before a patient receives a hemodialysis treatment? Select all that apply.
Before hemodialysis treatment, nurses assess laboratory values for BUN, potassium, phosphorus, and creatinine to determine if hemodialysis is necessary for impaired kidney function.
A nurse is monitoring a client who had a kidney biopsy for postoperative complications. Which of the following complications should the nurse identify as causing the greatest risk to the client?
Bleeding, infection, arteriovenous fistula, organ injury, and allergic reactions are common kidney biopsy complications. Nurses should report bleeding, infection, and allergic reactions to medical staff.
Which nursing diagnosis is the priority in the patient diagnosed with chronic kidney disease?
Chronic kidney disease patients face increased risk of fractures due to mineral and electrolyte imbalances. Addressing fracture risk is crucial for overall health and well-being. Anxiety, disturbed body image, and bleeding risk are not priority nursing diagnoses.
The nurse is preparing to discharge a patient with chronic kidney disease. In teaching the patient about calcium acetate tablets, which explanation by the nurse is best?
Calcium acetate lowers serum phosphate levels in chronic kidney disease patients by binding to dietary phosphate, maintaining electrolyte balance, and reducing complications.
A nurse administered captopril to a client during a renal scan. Which of the following actions should the nurse take?.
Captopril, an ACE inhibitor, can cause orthostatic hypotension during renal scans. To protect clients, observe symptoms. Limit fluid intake and encourage early ambulation to avoid complications and speed recovery.
The nurse is instructing a patient with iron deficiency anemia about appropriate menu choices. Which diet choice indicates that teaching has been effective?
broiled fish, lettuce salad, half a grapefruit, and carrot sticks for a nutritious iron-rich meal. Fish and leafy greens are rich in iron, while grapefruit provides vitamin C for absorption. Carrot sticks are also rich in iron, making this combination effective for iron deficiency anemia.
The nurse is administering peritoneal dialysis to a patient with acute kidney injury and notes the presence of a cloudy dialysate return. After notifying the healthcare provider, which action by the nurse is best?
After reporting cloudy peritoneal dialysis dialysate, nurses should culture it. This identifies the infection or peritonitis for prompt treatment. Measuring abdominal girth and documenting dialysate are relevant assessments, but they don't address the cloudiness's cause.
Which medication prescription for the patient with chronic kidney disease needs to be questioned by the nurse?
Assess medication impact on kidney function and toxicity for patients with chronic kidney disease. Healthcare professionals should make dosage adjustments. Avoid Demerol (meperidine) due to potential toxicity and consider alternative pain medications.
A nurse is planning care for a client who has Hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Assist with ambulation to prevent falls and injuries caused by anemia. Monitor oxygen saturation to assess oxygenation status/guide interventions. Obtain stool specimens for occult blood to identify gastrointestinal issues. Schedule daily rest periods to conserve energy/promote recovery.
The nurse is caring for a patient who is pale and experiencing fatigue secondary to anemia related to chronic kidney disease. When the patient's spouse asks why the patient is anemic, what response by the nurse is the best?
Chronic kidney disease causes anemia due to decreased erythropoietin production, a hormone responsible for stimulating red blood cell production in the bone marrow. Insufficient kidney function leads to decreased erythropoietin production, causing anemia.
Which finding in the patient four hours after cystoscopy requires an intervention by the nurse?
Dark-red urine after cystoscopy may indicate bleeding. Nurse should assess vital signs, monitor output, and notify healthcare provider. Further intervention may be necessary to address bleeding and ensure patient safety.
A nurse is assessing a client who has prerenal AKI. Which of the following findings should the nurse expect? (Select all that apply.)
Dehydration, low blood pressure, and heart failure reduce kidney blood flow, causing prerenal AKI. Untreated, it causes intrarenal AKI. Dehydration, decreased urine output, elevated BUN, creatinine, orthostatic hypotension, and BUN/Creatinine ratio. Early detection prevents renal damage.
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client's clotting factors are depleted? (Select all that apply.)
Disseminated intravascular coagulation (DIC) can be indicated by low platelet count and low fibrinogen levels, indicating depletion of clotting factors. Platelets can be 100,000/mm3 due to excessive clotting, while fibrinogen levels are 120 mg/dL.
The nurse recognizes which of the following as a component of plasma within the blood?
Electrolytes are recognized by nurses as a part of blood plasma. They help maintain fluid balance and cell function. Platelets, red blood cells, and white blood cells are different components of blood.
The nurse recognizes that a patient who presents in the emergency department with symptoms of a thrombotic stroke should be evaluated to receive which medication?
Emergency department patients with thrombotic stroke symptoms may receive Abciximab medication to prevent blood clotting and reduce brain clot formation. Other medications like Warfarin, Vitamin K, and Streptokinase may also be used, depending on the patient's condition and doctor's recommendation.
A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate?
Epistaxis is a common manifestation, resulting from depletion of platelets and clotting factors. Bradycardia, hypertension, and xerostomia are not typically associated with DIC.
Which clotting factor is converted to fibrin and is responsible for clot formation?
Fibrinogen becomes fibrin, forming blood clots. It's done by thrombin, derived from prothrombin. Calcium ions and tissue thromboplastin help, but don't directly convert into fibrin.
The nurse prioritizes which nursing diagnosis for the patient with a decreased neutrophil count?
For a patient with low neutrophil count, the nurse prioritizes "Risk for Infection" to prevent and manage infections due to reduced ability to fight them off.
Which statement by the patient diagnosed with chronic kidney disease who is prescribed furosemide (Lasix) indicates that teaching about this medication was effective?
Furosemide, a diuretic medication for chronic kidney disease, reduces swelling and excess potassium. It increases urine production and eliminates fluid and salt, while causing potassium loss to reduce hyperkalemia. Statement 4 accurately reflects the intended effects of furosemide.
Which statement by the patient diagnosed with polycystic kidney disease (PKD) indicates the need for further teaching?
Further teaching is needed to explain the importance of avoiding high-potassium foods and providing alternative options for breakfast for patients with polycystic kidney disease (PKD).
The nurse is caring for a male patient with hypersplenism. Which laboratory result does the nurse correlate to this disorder?
Hypersplenism occurs when the spleen overactivates, causing excessive blood cell destruction, leading to low platelet counts. The patient's platelet count is 120,000, below normal, but other laboratory results do not indicate hypersplenism.
Which statement by the patient being discharged after treatment for acute glomerulonephritis indicates the need for further teaching?
In acute glomerulonephritis, kidneys filter waste and excess fluid, requiring patients to reduce protein intake. High protein diets can worsen the condition, so it's crucial to educate patients about the importance of limiting protein intake to prevent kidney damage.
In providing an educational inservice to the nursing staff about peritoneal dialysis, which information does the nurse include in this presentation?
In an educational inservice, the nurse should mention the peritoneum as a semipermeable membrane for waste movement, allowing for diffusion and osmosis. However, incorrect options include excess metabolites, partial understanding of diffusion and ultrafiltration, and incorrect solute clearance.
In planning an educational presentation about age-related changes of the renal system, the nurse includes which information?
In an educational presentation, the nurse should mention age-related changes in the renal system, including kidney size, blood flow, urine concentration, and glomerular filtration rate (GFR).
The nurse monitors for which characteristics of urine in the patient with suspected renal impairment? Select all that apply.
In renal impairment, nurses look for clear, yellow urine, ammonia-like odor, pH 3.0, specific gravity 1.025, and proteinuria (10 mg/dL). Clear urine indicates proper hydration and renal function, while ammonia-like odor may indicate urinary tract infection or metabolic disorders.
What grade of renal trauma does should the nurse document in the patient who has a renal laceration that is greater than 1 cm in depth but does not involve the collecting system?
Nurse documents renal trauma as Grade 3 using AAST Organ Injury Scale, categorizing injuries into minor contusion, cortical laceration, greater than 1 cm deep, and laceration involving collecting system.
The nurse correlates which clinical manifestations in the patient diagnosed with a grade 1 renal trauma? Select all that apply.
Nurse identifies clinical manifestations of grade 1 renal trauma, including contusion, hematuria, superficial laceration, and nonexpanding hematoma. No renal artery injury is typically associated.
The nurse correlates which data in a patient's medical history as risk factors for acute kidney injury? Select all that apply.
Nurse identifies dehydration, renal calculi, low serum albumin, and hypertension as risk factors for acute kidney injury in patients with kidney stones, low serum albumin, or hypertension.
Which data in an older adult's history does the nurse correlate as risk factors for developing acute kidney injury? Select all that apply.
Nurse identifies risk factors for developing acute kidney injury in older adults, including hypotension diagnosis, recent aortic valve replacement surgery, prescribed antibiotics, and taking type 2 diabetes medication.
A patient with chronic kidney disease is experiencing manifestations of anemia. Based on this data, which treatment does the nurse anticipate for this patient?
Nurse may administer erythropoietin injections to patients with chronic kidney disease experiencing anemia. Erythropoietin stimulates red blood cell production, improving hemoglobin levels and alleviating anemia symptoms by increasing red blood cell production.
The nurse monitors for which therapeutic effect in the patient receiving sodium polystyrene sulfonate (Kayexalate) for the treatment of chronic kidney disease?
Nurse monitors decreased serum potassium levels in patients receiving sodium polystyrene sulfonate (Kayexalate) for chronic kidney disease treatment, ensuring normal levels and preventing hyperkalemia complications.
A nurse is reviewing the results of a client's urinalysis. The findings indicate the urine is positive for leukocyte esterase and nitrites. Which of the following actions should the nurse take?
Nurse obtains clean-catch urine specimen for culture and sensitivity to confirm UTI presence, identify organism, and select appropriate antibiotics. Avoid creatinine collection and indwelling catheters.
A nurse is planning care for a client who has prerenal acute kidney injury (AKI) following abdominal aortic aneurysm repair. Urinary output is 60 mL in the past 2 hr, and blood pressure is 92/58 mm Hg. The nurse should expect which of the following interventions?
Nurse should plan to administer a fluid challenge to correct prerenal acute kidney injury (AKI) caused by decreased blood flow to the kidneys. Other options, such as CT scan preparation, nitroprusside administration, and Trendelenburg positioning, are not appropriate.
In providing education to a patient diagnosed with renal carcinoma, the patient states, "My doctor says I am a stage 1. What does that mean?" Which response by the nurse is best?
Nurse should suggest Stage 1 renal carcinoma, indicating localized cancer and a better prognosis. Accurate information helps patients understand the extent of the cancer and make informed decisions about treatment and care.
A nurse is caring for a client who has a urinary tract infection (UTI). Which of the following is the priority intervention by the nurse?
Nurses should administer antibiotics as the primary intervention for clients with urinary tract infections (UTI) to treat and prevent spread. Other interventions, like warm sitz baths and cranberry juice, do not address the underlying infection.
A nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Nurses should monitor dysrhythmias, jugular vein distention, pleural friction rub, mouth rinses, and a high-sodium diet in Stage 4 chronic kidney disease patients. These actions manage fluid balance, blood pressure, and client monitoring.
The nurse monitors for which diagnostic results in a patient with impaired renal function? Select all that apply.
Nurses should monitor serum creatinine, blood urea nitrogen, glomerular filtration rate (GFR), electrolyte levels, urine output, proteinuria, and urinalysis for patients with impaired renal function. These tests help assess kidney function and identify abnormalities.
The nurse is planning care for the patient with acute kidney injury. Which assessment data best supports the nursing diagnosis Excess Fluid Volume?
Pitting edema in the lower extremities supports the nursing diagnosis of fluid overload. Positive bowel sounds, wheezing lungs, and fatigue are nonspecific symptoms unrelated to fluid volume.
In providing care to the patient who may have polycystic kidney disease, the nurse recognizes which finding as the first clinical manifestation of this disease process?
Polycystic kidney disease (PKD) typically presents as hypertension, which is the first clinical manifestation, and not other signs like hematuria, urinary frequency, or calculi.
During a home visit, the nurse is concerned that an older adult patient is developing chronic kidney disease. Because the patient has no history of cardiovascular disease, what data requires further consideration by the nurse?
Progressive edema is a common sign of chronic kidney disease (CKD). Edema can result from kidney failure. Explore possible causes with more testing.
The nurse correlates which disorder to the development of intrarenal renal failure?
Prolonged hypotension leads to intrarenal renal failure, a condition caused by kidney damage or dysfunction. It affects kidney function and can result from other conditions like glomerulonephritis, renal calculi, and hypovolemia.
A nurse is caring for several clients. Which of the following clients are at risk for developing pyelonephritis? (Select all that apply.)
Pyelonephritis is more likely in clients with kidney calculi, a neurogenic bladder, and diabetes mellitus, as kidney stones, nerve problems, and weak immune systems increase the risk of infection.
A nurse is reviewing client laboratory data. Which of the following findings is expected for a client who has Stage 4 chronic kidney disease?
Stage 4 chronic kidney disease leads to significant impairments in kidney function, with elevated BUN levels, reduced GFR, elevated creatinine levels, and elevated potassium levels. These findings indicate impaired kidney function and potential normal potassium levels.
The nurse monitors for which electrocardiogram change as the first indication of hyperkalemia in the patient with acute kidney disease?
Tall T waves are a classic ECG sign of hyperkalemia in patients with acute kidney disease, indicating potential cardiac arrhythmias. Early recognition is crucial for prompt intervention.
Which physiologic factors result in the secretion of aldosterone from the kidneys? Select all that apply.
The RAAS regulates kidney aldosterone secretion in response to blood pressure, electrolyte balance, and fluid volume. Aldosterone secretion requires hypokalemia, hypotension, or hyperkalemia. Hypernatremia regulates sodium balance by kidney reabsorption, not aldosterone secretion.
What grade of renal trauma does the nurse document in the patient experiencing hematuria and contusions, but with normal imaging studies?
The nurse documents Grade 1 renal trauma for the patient, a minor injury without significant damage. The patient experiences hematuria and contusions, but normal imaging studies show no structural damage.
A patient with a history of hypertension is diagnosed with chronic kidney disease. When the patient asks the nurse how this occurred, which response by the nurse is the best?
The nurse should explain that high blood pressure reduces renal blood flow, damaging kidney tissue and causing chronic kidney disease (CKD). Hypertension causes kidney damage and CKD. Option 3 accurately describes the patient's hypertension.
A nurse is teaching a client who will have an x‑ray of the kidneys, ureters, and bladder. Which of the following statements should the nurse include in the teaching?
The nurse should explain the KUB x-ray's non-contrast dye, enema-free nature, kidney stone detection potential, and painless procedure. To reduce anxiety and prepare clients for their unique needs, remove metal objects and follow healthcare provider or radiology department instructions.
A nurse is caring for a client who has type 2 diabetes mellitus and will have excretory urography. Prior to the procedure, which of the following actions should the nurse take? (Select all that apply.)
The nurse should identify seafood allergies, temporarily withhold metformin for 24 hours to reduce lactic acidosis risk, administer an enema for clear images, obtain a blood coagulation profile to assess clotting ability, and assess asthma before excretory urography.
The nurse is caring for a patient admitted with a diagnosis of acute kidney injury. The patient asks the nurse, "Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is the most appropriate?
The nurse should provide accurate and hopeful information about kidney failure and transplant need, acknowledging the patient's concerns and reassuring them that prompt treatment can reverse their condition and prevent kidney damage.
Which medications does the nurse identify as potentially nephrotoxic when conducting a health history exam for a patient who is admitted for acute kidney disease? Select all that apply.
The nurse should recognize Ibuprofen, Lithium, Rifampin, and Phenazopyridine in acute renal disease patients' health histories. Lithobid is a bipolar disorder medicine, while ibuprofen is an NSAID. Acute interstitial nephritis can result from rifampin usage.
Which statement by the patient diagnosed with pyelonephritis indicates the need for further teaching?
The patient appears to misunderstand phenazopyridine's role in treating UTIs. Inform them that phenazopyridine relieves symptoms and that antibiotics must be taken as prescribed.
Which statement by the 65-year-old female patient about age-related changes to urinary function indicates the need for further teaching?
The statement "my risk of urinary infections decreases as I age because of changes in vaginal pH" is incorrect. The risk of UTIs increases with age, especially in older women. Further education is needed to correct this misconception.
Which statement by the patient after radical nephrectomy for renal cancer indicates the need for further teaching?
The statement suggests further teaching about changing bed positions to reduce pneumonia risk, but it doesn't directly decrease the risk. Pneumonia is primarily caused by infection, not body positioning. It's crucial to clarify patient understanding of this aspect.
What term does the nurse use to document a patient's complaints of blood in the urine?
The term the nurse uses to document a patient's complaints of blood in the urine is "hematuria." Hematuria refers to the presence of blood in the urine, which can be a sign of various underlying conditions or diseases.
A nurse is planning care for a client who has postrenal AKI due to metastatic cancer. The client has a blood creatinine of 5 mg/dL. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
To care for a client with postrenal AKI caused by cancer and a 5 mg/dL blood creatinine level, nurses should monitor fluid balance, maintain hydration, collaborate for renal imaging, provide pain management, consult urology, and monitor for infection signs.
A nurse is preparing educational material to present to a female client who has frequent urinary tract infections. Which of the following information should the nurse include? (Select all that apply.)
To prevent urinary tract infections, nurses should advise female clients to avoid wet bathing suits, wipe the perineal area back to front after elimination, empty the bladder regularly, and wear cotton underwear for air circulation.
A nurse is reviewing urinalysis results for four clients. Which of the following urinalysis results indicates a urinary tract infection?
Urinalysis results indicate urinary tract infection (UTI) if positive for leukocyte esterase, indicating white blood cells in urine. Positive results indicate kidney damage, ketones, or kidney stones, but not UTIs.
Place the stages of hemostasis in the correct order
When a blood vessel is damaged, the stages of hemostasis occur in this order: vessel constriction, platelet plug formation, clotting, clot shrinkage, and clot dissolution.
When planning meals for the patient with chronic kidney disease, which dietary choices are best for this patient?
When planning meals for chronic kidney disease patients, consider dietary restrictions. Low-sodium, potassium, and phosphorus carrots and green leafy vegetables are ideal. Hamburgers with bananas, cold cuts with pears, and spaghetti and meat sauce may not be kidney-friendly.
When teaching the patient with chronic kidney disease and hypertension to avoid salt substitute, the nurse bases this instruction on which rationale?
potassium chloride salt substitutes increase hyperkalemia, causing kidney disease and hypertension. Avoiding high-potassium salt substitutes helps patients avoid hyperkalemia and complications. To avoid these issues, doctors should instruct.
A nurse is planning care for a client who has chronic pyelonephritis. Which of the following actions should the nurse plan to take? (Select all that apply.)
the nurse should provide nutrition counseling, encourage daily fluid intake of 1 L, palpate the costovertebral angle, monitor urinary output, and administer antibiotics. These actions help maintain kidney function, prevent infections, and ensure long-term treatment.
The nurse provides care for a patient who is diagnosed with a folic acid deficiency anemia. Which clinical manifestation requires healthcare provider notification?
Folic acid deficiency affects the nervous system, and confusion indicates the brain may not be getting enough of the nutrient. Symptoms like pallor, breathing, and fast heart rate are also associated with this condition.
The nurse correlates which diagnostic finding to a diagnosis of multiple myeloma?
Multiple myeloma is a cancer affecting bone marrow plasma cells, causing high levels of calcium in the blood. A serum calcium level of 8.5 mg/dL is the best indicator of a correlation to multiple myeloma.
The nurse correlates appropriate secondary polycythemia to which of the following conditions?
Often due to renal disease. Excess erythropoietin from kidneys increases red blood cell production. Renal disease causes polycythemia, cancer can cause secondary polycythemia. Cold and high altitudes increase red cell production but don't cause secondary polycythemia.
A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion?
Prioritize assessment for acute hemolytic reaction during the first 15 minutes of a packed red blood cell transfusion for a client with 8 g/dL hemoglobin. Monitor closely, obtain consent, and obtain blood culture specimens to ensure client safety.
A patient diagnosed with polycythemia is prescribed radiation, and asks the rationale for this treatment. Which response by the nurse is accurate?
Radiation therapy is prescribed for polycythemia due to its ability to suppress the bone marrow's red blood cell production, normalizing blood cell count and alleviating symptoms. This treatment is often used to treat the condition.
The nurse includes which statement in teaching a patient scheduled for intravenous urography?
In intravenous urography, a diagnostic test, contrast dye is injected into the bloodstream to visualize the urinary system. Increased fluid intake is crucial to flush out the dye and prevent complications like kidney damage or dehydration.
The nurse is providing care to a patient who states, "My doctor says I am experiencing nocturia. What does that mean?" Which response by the nurse is best?
Nurse should answer nocturia as waking up frequently at night to urinate, as options 1, 2, and 4 do not accurately define the condition and may cause confusion or misinformation.
Which is an age-related hematological change the nurse anticipates when reviewing a complete blood count (CBC) for an older adult patient?
Inflammation, infection, and diseases can increase blood sedimentation rate as people age. Hematocrit and hemoglobin increases are not usually associated with aging. Immune system changes rarely increase B and T cells. Based on a patient's medical history, consult a doctor.
A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching?
Nurse should mention that consuming vitamin C-rich foods enhances ferrous sulfate absorption, promoting optimal therapeutic effects and converting iron into a more absorbable form.
In completing a physical assessment on a patient, the nurse notes that the patient has a red, swollen, smooth, shiny and tender tongue. The nurse correlates this finding to which disorder?
Iron deficiency anemia can cause glossitis, tongue inflammation. Glossitis makes the tongue red, swollen, and shiny. Inflammation may cause tenderness. Thrombocytosis, leukopenia, and vitamin K deficiency rarely cause these tongue findings.
The nurse conducts a teaching session for a patient who is diagnosed with iron deficiency anemia. Which patient statement indicates to the nurse a need for additional teaching?
Iron deficiency anemia is caused by a lack of iron in the body, and eggs are a good protein source but not a significant source of iron. This suggests a need for additional teaching on dietary iron sources.
Which statement by a 65-year-old patient diagnosed with aplastic anemia secondary to chemotherapy indicates the need for further teaching?
Patient requires additional education on treating aplastic anemia. Bone marrow produces insufficient blood cells. Drugs help, but bone marrow transplant is the primary cure. Teaching needed to differentiate aplastic anemia treatment.
In the patient with metabolic acidosis, what is the role of the kidneys in acid-base balance?
The kidneys reabsorb bicarbonate and excrete hydrogen ions to maintain acid-base balance in metabolic acidosis patients. They control hydrogen, bicarbonate, sodium, calcium, and electrolytes, but not acid-base equilibrium.
The nurse is providing care to a patient who is experiencing symptoms of a kidney stone. Which diagnostic tool does the nurse anticipate will be ordered for this patient?
Imaging tests such as X-rays, CT scans, ultrasounds, urinalysis, blood tests, and serum creatinine and blood urea nitrogen tests aid in diagnosing kidney stones. Tests detect kidney stones, complications, and function.
Which statement by the female patient about the collection of a clean-catch urine sample indicates the need for further teaching?
Further teaching is needed on proper technique for wiping labia from front to back, as back-to-front wiping can introduce bacteria from anal area to urethra.
The nurse provides education to a patient diagnosed with a folic acid deficiency. Which patient statement indicates a correct understanding of the dietary information presented?
Green, leafy vegetables such as spinach, kale, and broccoli are good sources of folic acid. Consuming more of these vegetables can help address a folic acid deficiency.
The nurse is caring for an older adult patient with hemolytic anemia. When planning care for this patient, which should the nurse take into consideration regarding this diagnosis? Select all that apply.
Hemolytic anemia is a condition causing premature red blood cell destruction, increasing reticulocytes. It's caused by immune system dysfunction or genetic abnormalities. Treatment varies and may not require folic acid supplementation.
A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering?
Heparin is an anticoagulant medication commonly used in the management of DIC. Vitamin K is not typically administered in DIC.
The nurse develops the nursing diagnosis "Risk for Bleeding related to lack of intrinsic factor" for the patient with which hematological disorder?
Pernicious anemia patients have a nursing diagnosis of("Risk for Bleeding")due to a lack of intrinsic factor protein, crucial for absorbing vitamin B12 and producing healthy red blood cells. This diagnosis is specific to pernicious anemia and not other hematological disorders.
Which term does the nurse use when documenting an elevated red blood cell (RBC) count?
Polycythemia is a condition involving an increased number of red blood cells in the bloodstream, caused by factors like dehydration, smoking, and high altitudes. Anemia, neutropenia, and thrombocytopenia are conditions affecting red blood cells, neutrophils, and platelets.
The nurse correlates a potential for decreased oxygenation in the female patient with which laboratory results?
The nurse suspects decreased oxygen levels in the female patient, which is related to her Hemoglobin level of 12.0 g/dL. Hemoglobin carries oxygen in the blood, so a lower level could mean less oxygenation.
The nurse teaches a patient to increase the intake of which hematopoietic vitamins to promote red blood cell formation and function? Select all that apply.
To form and function red blood cells, nurses advise patients to take more folic acid and vitamin B12. Folic acid helps DNA growth and B12 protects nerve cells. B6, C, and K vitamins are not involved.
The nurse encourages the patient with iron deficiency anemia to increase which food in the diet?
To improve iron deficiency anemia, the nurse advises the patient to eat more shellfish, lima beans, citrus fruits (for vitamin C), and consider consuming milk products separately from iron-rich foods.
The nurse is reviewing laboratory results for a patient scheduled for a bleeding time test. Which value requires an immediate intervention?
To prevent excessive bleeding, nurses should treat a patient's 70,000/mm3 platelet count. This indicates clotting issues and increases bleeding risk during and after a bleeding time test. Nurses should notify doctors and order platelet transfusions or further testing.
Which actions does the nurse implement in the patient who is neutropenic? Select all that apply.
To protect neutropenic patients with weakened immune systems, nurses should wash hands before touching them, limit visitors, and educate visitors on proper hand hygiene. This creates a clean and safe environment, reducing the risk of infections.
In providing care to a patient with suspected urinary retention, the nurse prepares the patient for which diagnostic study?
Ultrasonic bladder scan is a common diagnostic test for urinary retention, using ultrasound technology to assess urine levels. Urinalysis examines urine composition, while intravenous urography visualizes urinary system on X-rays. Cystoscopy is a more invasive procedure,
The nurse provides care to a patient who presents with clinical manifestations of an ischemic stroke. Which time frame does the nurse anticipate for the prescribed fibrinolytic medication?
Ischemic stroke patients should be given fibrinolytic medication within 4 hours by nurses. This timeframe allows effective administration, but guidelines and timeframes may vary. Nurses should consult doctors and follow fibrinolytic medication guidelines.
A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect?
Koilonychia, a common sign of iron deficiency anemia, is a spoon-shaped nail condition. Shiny, hairless legs are not directly associated with anemia, and yellow mucous membranes indicate jaundice.
In providing care for a patient who takes 325 mg aspirin daily, the nurse teaches the patient that with long-term aspirin therapy, which laboratory tests need to be periodically monitored? Select all that apply.
Long-term aspirin users must monitor INR, prothrombin time, and serum creatinine. Blood clotting, anticoagulation, and kidney function are tested. Aspirin therapy must be personalized by a doctor to be safe and effective.
The nurse monitors which laboratory results in the patient with a clotting disorder caused by the intrinsic pathway?
Monitor (Partial Thromboplastin Time)PTT in patients with intrinsic clotting disorders to assess blood clotting time and evaluate clotting factors. PTT is the best way to track a patient's condition, as other tests are not directly related to clotting disorders.
The nurse monitors for which clinical manifestations in the patient diagnosed with malignant lymphoma? Select all that apply.
Monitor signs and symptoms i.e night sweats, high fevers, swollen lymph nodes, painful lymph nodes, and unexplained weight loss. These manifestations help nurses understand the disease's progress and provide appropriate care.
The nurse monitors for which assessment data in the patient diagnosed with a kidney infection?
Monitor urine color, output, costovertebral angle tenderness, and ammonia-like odor to assess kidney function, infection severity, and treatment effectiveness. Monitor changes in urine output, costovertebral angle tenderness, and urine odor to identify potential worsening or response to treatment.
A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? (Select all that apply.
Monthly injections of vitamin B12 are reliable for adequate levels, while oral supplements may be an option. Increased intake of animal proteins, legumes, and dairy products can supplement vitamin B12 levels.
The nurse is planning care for a patient with acute myeloid leukemia (AML). Which is the priority nursing diagnosis to minimize the risk of complications associated with this diagnosis?
Prioritize the nursing diagnosis of "Risk for Bleeding" to minimize complications in patients with acute myeloid leukemia (AML). Address factors like low platelet count, ulcerations, invasive procedures, and anticoagulant medications.
In administering cryoprecipitate to a patient diagnosed with idiopathic thrombocytopenia purpura, the nurse recognizes which of the following actions as the rationale for this treatment?
Provides clotting factors. Cryoprecipitate, a blood product derived from FFP, is used to provide clotting factors for patients with bleeding disorders or deficiencies. It does not directly increase platelet count or prevent platelet destruction
The nurse recognizes which as a function of red blood cells?
Red blood cells carry oxygen from the lungs to the body's tissues. This is their main function. They also help transport carbon dioxide, but oxygen transport is their primary role.
The nurse is providing care to a patient who states, "My doctor says I am experiencing renal colic. What does that mean?" Which response by the nurse is best?
Renal colic is severe, crampy pain caused by a kidney stone passing through the urinary tract, originating in the flank area and radiating to the groin. Nurses should accurately explain this.
An older adult patient with renal failure is diagnosed with anemia. Based on this data, which cause of anemia will the nurse include in the plan?
Renal failure causes kidney dysfunction, affecting erythropoietin production, causing anemia. The kidneys' inability to produce enough erythropoietin leads to a decrease in red blood cell production, resulting in a low level of red blood cells.
The nurse correlates which laboratory result as the most reliable indicator of impaired renal function?
Serum creatinine level of 2.4 mg/dL is the most reliable indicator of impaired renal function, as it is a waste product filtered by kidneys and is influenced by factors like dehydration and diet.
The nurse is providing care to a patient who states, "My doctor says I am experiencing urinary retention. What does that mean?" Which response by the nurse is best?
Nurse correctly explains urinary retention as inability to fully empty bladder, causing urine accumulation, providing a clear understanding of the patient's condition.
What term does the nurse use to document a patient's complaints of painful urination?
Nurse documents patient complaints of painful urination as Dysuria, referring to discomfort, burning, or pain, while Anuria, Enuresis, and Hematuria describe absence, involuntary, and blood presence.
A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client?
Nurse ensures client's hemoglobin checks twice a week to assess erythropoietin therapy effectiveness, improve red blood cell production, and guide dosage adjustments.
The nurse recognizes which prescribed medication is indicated to prevent the formation of clots for a patient diagnosed with deep vein thrombosis (DVT)?
Nurse prescribes Warfarin to prevent clot formation in patients with deep vein thrombosis (DVT). Warfarin inhibits clotting factors production and is taken orally. Vitamin K is used as an antidote. Abciximab and streptokinase are not commonly used for DVT prevention.
The nurse is assisting the healthcare provider with a bone marrow aspiration and biopsy on a patient who has leukemia. The patient also has thrombocytopenia. On completing of the test, which intervention is a priority for the nurse?
Nurse prioritizes applying pressure to bone marrow biopsy wound for 5-10 minutes to prevent bleeding, especially with low platelet count. Other options include infection signs, specimen labeling, and pain assessment.
A patient with a history of anemia has started a vegan diet. Which addition to meals should the nurse recommend to help ensure that this patient has adequate amounts of iron in the diet? Select all that apply.
Nurse recommends incorporating legumes, dark leafy greens, nuts, seeds, and whole grains in vegan diets for iron intake, preventing anemia. Orange juice aids in absorption, while brewer's yeast, okra, and peas contribute to overall nutrition.
A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching?
Nurse recommends making an appointment to donate blood 8 weeks before surgery for autologous donation, allowing ample time for multiple donations and replenishment, ensuring an adequate supply for the client during or after the procedure.
A nurse is teaching a newly licensed nurse about heparin‑induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?
Nurse should consider heparin therapy for deep-vein thrombosis as a risk factor for heparin-induced thrombocytopenia (HIT), as it is a major risk factor. HIT can occur in any patient receiving heparin, regardless of other factors.
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.)
Nurse should identify febrile transfusion reactions by observing temperature changes, heart rate changes, current blood pressure, itching, and flushing.
A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small‑vessel clotting when which of the following is assessed?
Nurse should report petechiae on upper chest, which may indicate bleeding tendencies and small-vessel clotting in clients with ITP. Notifying the healthcare provider is crucial for appropriate management and intervention.
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse plan to take if an allergic transfusion reaction is suspected? (Select all that apply.)
Nurse should stop allergic transfusion, maintain IV infusion with 0.9% sodium chloride, and administer diphenhydramine to minimize reaction severity and provide emergency medication.
What term does the nurse use to document a patient's complaints of involuntary urination at night?
Nurses document patients' complaints of involuntary urination at night, known as enuresis, during sleep. Accurate documentation is crucial for proper diagnosis and treatment. Anuria, dysuria, and hematuria are common symptoms.
The nurse monitors for which diagnostic result in the patient with glucose-6-phosphate dehydrogenase (G6PD) deficiency?
Nurses monitor patients with G6PD deficiency for Heinz bodies, abnormal structures in damaged red blood cells, to assess damage and ensure appropriate care. This helps prevent complications and ensures proper treatment.
The nurse provides care to a patient who is admitted for a sickle cell disease (SCD) crisis. Which is the priority prescription for the nurse to implement when providing patient care?
Nurses prioritize pain medication for patients with sickle cell disease crises, as it is crucial for comfort and well-being. Other actions, like oxygen, antipyretics, and intravenous fluids, are important after addressing pain.
The nurse prepares to administer the prescribed intramuscular injection (IM) iron to a patient. Which is the priority action for this task?
Nurses should check for fast heart rate (tachycardia) during intramuscular iron injections to prevent allergic reactions. Prioritizing this over other actions like Z-track method, pressure, and monitoring side effects is crucial.
A nurse is planning care for a patient with sickle cell disease. The nurse should contact the provider about which prescribed intervention?
Nurses should contact providers to administer analgesic medications 24/7 for patients with sickle cell disease to manage severe pain crises effectively. Other interventions, such as continuous pain relief, do not require immediate provider notification.
Which is the priority teaching point for the nurse to include in the discharge instructions for the patient being discharged after treatment for sickle cell crisis?
Nurses should prioritize ensuring patients stay well-hydrated and drink enough fluids after treatment for sickle cell crisis to prevent worsening pain and complications. Other instructions include reducing pain medications, maintaining a healthy diet, and avoiding strenuous activities.
A patient with sickle cell crisis is admitted to the emergency department, with a temperature of 102°F, 89% O2 saturation, and severe abdominal pain. The nurse assesses the patient and determines the most priority intervention?
Nurses should prioritize providing oxygen through a nasal cannula to patients experiencing sickle cell crisis, as low oxygen levels can be harmful. Prioritizing oxygenation is the most urgent step, and other actions can be delayed.
In observing a new graduate nurse palpating a patient's kidneys during a physical examination, which observation requires an intervention by the nurse?
Observing a graduate nurse palpatating a patient's kidneys during a physical examination requires intervention. The correct position is under the patient's back, just above the waistline, and the abdomen from the front, just above the rib cage.
A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Obtain vital signs every 15 minutes during blood transfusions to assess client response and ensure safety. Avoid inserting an 18-gauge IV catheter, verifying blood compatibility and expiration date with assistive personnel, and administering dextrose 5% in 0.9% sodium chloride IV.
What term does the nurse use when documenting that the patient has less than 100 mL of urine output in a 24-hour period?
Oliguria is a term used to describe a patient's decreased urine output, typically less than 400 mL in 24 hours. Other options include anuria, dysuria, and enuresis, which refer to painful or difficult urination.
The nurse correlates which diagnostic results to the patient with pancytopenia? Select all that apply.
Pancytopenia is low blood cell levels. To diagnose pancytopenia, a nurse should look for decreased reticulocyte count, platelets, and RBC count of 3.2 million cells/mm^3, indicating low oxygen levels.
A nurse is providing discharge instructions to a patient with iron deficiency anemia who is experiencing glossitis. Which patient statement indicates the need for further education?
Patient needs further education on using alcohol-based mouthwash twice daily to worsen tongue inflammation. Other correct statements include monitoring lips and tongue daily, applying petroleum-based ointment, and using a soft toothbrush for daily teeth brushing.
The home healthcare nurse is preparing a care plan for a patient with severe anemia. The patient currently lives alone and states, "I can't even walk to the kitchen without getting winded." What would be the priority nursing diagnosis for this patient?
Severe anemia patients with activity Intolerance face challenges in daily tasks, requiring nurses to improve exercise and independence through monitoring vital signs, gradually increasing activity, teaching energy-saving techniques, and collaborating with healthcare providers.
The nurse correlates an intact immune system with the function of which stem cells? Select all the apply.
Stem cells help the immune system function. B lymphocytes, neutrophils, and T lymphocytes, which coordinate the immune response, are stem cells. Immunity depends on these stem cells. Granulocytes and thrombocytes (are not stem cells and) do not affect immune system integrity.
A nurse is caring for a client who is receiving warfarin for anticoagulation therapy. Which of the following laboratory test results indicates to the nurse that the client needs an increase in the dosage?
The International Normalized Ratio (INR) is a laboratory test for determining dosage adjustment in warfarin anticoagulation therapy. A 1.1 INR indicates inadequate blood anticoagulation, suggesting an increase in warfarin dosage to achieve desired therapeutic range.
A nurse is providing teaching for a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates an understanding of the teaching?
The correct answer is "I will need to stay in bed for about an hour after the test," as the bone marrow biopsy typically occurs while the client is lying on their side.
The nurse recognizes that the patient with blood loss is at risk of renal damage because the kidney receives what percentage of the total cardiac output?
The kidneys receive 20% to 25% of cardiac output, enabling efficient waste product filtering, electrolyte balance regulation, and fluid homeostasis. Reduced blood volume in hemorrhage can compromise renal function, requiring monitoring and addressing to prevent complications.
In providing care for a patient with malignant lymphoma, the nurse correlates which clinical manifestations to the development of superior vena cava syndrome?
The most common symptom is shortness of breath because the blockage increases the pressure in the upper body, making it difficult for the person to breathe properly. Other symptoms may include swelling of the face, neck, and arms.
The nurse analyzes a female patient's CBC count, which includes platelets, hemoglobin, red blood cells, and white blood cells. The patient's hemoglobin is 15 g/dL, and red blood cells are 4.4 million cells/mm3.
The nurse reviewed a female patient's blood test results, finding normal values without low red or white blood cell counts, low platelet count, or anemia. No significant issues were detected, indicating normal results.
A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect?
The nurse should expect iron levels within the reference range, red blood cell counts (RBC) of 6.5 million/uL, white blood cell counts (WBC) of 4,800 mm³, and hemoglobin 10g/dl levels below the reference range for anemia.
The nurse is providing care to a patient who has impaired platelet aggregation. What does the nurse anticipate based on this data?
The nurse suspects the patient with impaired platelet aggregation is taking anti-inflammatory agents, which may affect platelet function, increasing bleeding risk. Other options like vitamin K, folic acid, and B12 supplements are not directly related to the issue.
The nurse is providing care to a patient who states, "My doctor says I am experiencing urinary urgency. What does that mean?" Which response by the nurse is best?
The nurse's response accurately reflects urinary urgency, a strong, compelling desire to urinate that is difficult to postpone. Urinary urgency is characterized by a sudden, intense need to urinate, often accompanied by discomfort or pressure in the bladder.
A patient experiencing fatigue, pallor, and dyspnea on exertion has a complete blood count completed. The nurse correlates these clinical manifestations to which hematological disorder?
The patient experiences fatigue, pale skin, and shortness of breath during physical activity, likely due to anemia, a decrease in red blood cell or hemoglobin levels. Other options like polycythemia, thrombocytopenia, and neutropenia are less likely to cause these symptoms.
Which statement to the nurse by the patient about a planned bone marrow biopsy indicates the need for further teaching?
The patient needs further teaching about a planned bone marrow biopsy, as they believe strict bedrest is unnecessary after the procedure. They may resume normal activities with some restrictions after the biopsy. Further teaching is needed to clarify the misunderstanding.
The nurse is providing discharge teaching for a patient with iron deficiency anemia. The patient has been prescribed ferrous sulfate and has been told to increase the intake of foods that are naturally high in iron. Which patient statement indicates the need for additional teaching?
The patient's statement suggests additional teaching on taking ferrous sulfate on an empty stomach, as it can decrease absorption and cause side effects. It is recommended to take it with food or after a meal to optimize its effectiveness.
The nurse is evaluating a patient's understanding of dietary needs to treat anemia. Which patient statement indicates a need for additional teaching?
The patient's statement suggests reducing foods high in vitamin C to decrease iron absorption, but this is incorrect as vitamin C enhances iron absorption, not decreasing it. It requires further clarification from the nurse.
In providing care to a patient with hyperglycemia and normal renal function, the nurse correlates the renal threshold for glucose to which value?
The renal threshold for glucose is the plasma glucose concentration at which the kidneys excrete glucose into urine, typically 180-200 mg/dL.
The nurse provides discharge instructions to a patient who is neutropenic. Which patient statements indicate the need for additional teaching? Select all that apply.
They should avoid handling plants, avoid raspberries and blackberries, use a humidifier, wash raw vegetables thoroughly, and complete the full course of antibiotics, even if feeling better, to prevent infection recurrence or antibiotic resistance.
What term does the nurse use to document a decreased platelet count?
Thrombocytopenia to describe decreased platelet count, which is crucial for blood clotting. This condition increases bleeding risk and difficulty in forming blood clots. It differs from anemia, which decreases red blood cells, and neutropenia, which decreases white blood cells.
The nurse prepares the patient with complaints of burning on urination for which diagnostic study?
Urinalysis analyzes urine samples for bacteria, white blood cells, and red blood cells, helping healthcare professionals identify the underlying cause and determine appropriate treatment.
The nurse is providing care to a patient at a local clinic. The nurse suspects that the patient is experiencing a urinary tract infection. Which urinalysis result supports the nurse's suspicions?
Urinalysis results suggest a urinary tract infection, with WBCs 10-15 indicating inflammation. A definitive diagnosis requires clinical symptoms, physical examination, and laboratory tests.
A nurse educator is teaching a group of patients about prevention of sickle cell crises. What should the nurse instruct about the precipitating factors that could contribute to a sickle cell crisis? Select all that apply.
sickle cell crisis triggers like altitude, fever, and vomiting. High altitude reduces oxygen, making it difficult for sickle cells to transport enough oxygen. Fever can raise crisis risk, often from infection. Vomiting often raises sickle cell concentration and crisis risk.
