Unit 2 Nursing Sem 3 PBSC

Which action will the nurse include in the plan of care for a 42 yearold patient who is being admitted with Clostridium difficile? a. Educate the patient about proper food storage. b. Order a diet with no dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used

ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile

A patient complains of leg cramps during hemodialysis. The nurse should first? a. massage the patient's legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline

ANS: D Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps

Which is not a function of the liver? A- metabolism of hormones B- production of bile C- Absorption of water D- Production of albumin

Ans: C- Absorption of water

The nurse is caring for a 68yearold hospitalized patient with a decreased glomerular filtration rate who is scheduled for an intravenous pyelogram (IVP). Which action will be included in the plan of care? a. Monitor the urine output after the procedure. b. Assist with monitored anesthesia care (MAC). c. Give oral contrast solution before the procedure. d. Insert a large size urinary catheter before the IVP

ANS: A Patients with impaired renal function are at risk for decreased renal function after IVP because the contrast medium used is nephrotoxic, so the nurse should monitor the patient's urine output. MAC sedation and retention catheterization are not required for the procedure. The contrast medium is given IV, not orally

A 42yearold patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input

ANS: A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72yearold man who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily

ANS: A The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels

A 42yearold patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate)

ANS: B Because hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure.

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.

ANS: B Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of a. persistent skin tenting b. rapid, deep respirations. c. bounding peripheral pulses. d. hot, flushed face and neck.

ANS: B Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix). due. Which action should the nurse take? a. Administer both drugs. b. Administer the spironolactone. c. Withhold the spironolactone and administer the furosemide. d. Withhold both drugs until discussed with the health care provider

ANS: B Spironolactone is a potassium sparing diuretic and will help increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.

A 62yearold female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is <30 mL/min/1.73m

ANS: B The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy

A 53yearold patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.

ANS: B The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.

Which intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein? a. Start continuous pulse oximetry. b. Restrict physical activity to bed rest. c. Restrict the patient's oral protein intake. d. Discontinue the urethral retention catheter.

ANS: B The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry

To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.

ANS: B The protein in the blood in the gastrointestinal (GI) tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode

A hospitalized patient with possible renal insufficiency after coronary artery bypass surgery is scheduled for a creatinine clearance test. Which equipment will the nurse need to obtain? a. Urinary catheter b. Cleaning towelettes c. Large container for urine d. Sterile urine specimen cup

ANS: C Because creatinine clearance testing involves a 24hour urine specimen, the nurse should obtain a large container for the urine collection. Catheterization, cleaning of the perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this test

A 49yearold female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 140/90 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/minute

ANS: C Because the purpose of beta blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with a. antibiotics. b. antifungals. c. anticoagulants. d. antihypertensives

ANS: C Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure

A 37 year old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

ANS: C GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for a. potassium level. b. total cholesterol. c. serum phosphate. d. serum creatinine

ANS: C If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a. Encourage adolescents and young adults to avoid crowds in the winter. b. Vaccinate 11 and 12yearold children against Haemophilus influenzae c. Immunize adolescents and college freshman against Neisseria meningitides d. Emphasize the importance of hand washing to prevent the spread of infection

ANS: C The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic

A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine volume b. Calcium level c. Cardiac rhythm d. Neurologic status

ANS: C The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate

Which statement by a 62yearold patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to get most of my protein from lowfat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take erythropoietin to boost my immune system and help prevent infection."

ANS: C The patient with endstage kidney disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

When assessing a 53yearold patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient exhibits nuchal rigidity. b. The patient has a positive Kernig's sign. c. The patient's temperature is 101°F (38.3°C). d. The patient's blood pressure is 88/42 mm Hg

ANS: D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices

ANS: D TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

ANS: D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters should also be monitored, but they are not directly associated with the patient's current symptoms.

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse should give priority to which client history item? a-Black, tarry stools b-Frequent nausea c-Joining Alcoholics Anonymous d-Pain that increases after meals

ANS: A-black, tarry stools The priority is black (tarry) stools that indicate upper gastrointestinal (GI) bleeding; digestive enzymes act on the blood, resulting in tarry stools. Hemorrhage can occur if erosion extends to blood vessels. Nausea is a common symptom of gastritis but is not life threatening. Attempts to control alcoholism should be supported, but this is a long-term goal; assessment of bleeding takes priority. Investigation of bleeding takes priority; later the nurse should help to identify irritating foods that may be increasing the pain after eating and are to be avoided.

To prepare a 56yearold male patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side

ANS: C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

A 38 year old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Place the patient on a pressure relieving mattress. d. Perform passive range of motion daily.

ANS: C The pressure relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.

Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? a. Splitpea soup, English muffin, and nonfat milk b. Oatmeal with cream, half a banana, and herbal tea c. Poached eggs, wholewheat toast, and apple juice d. Cheese sandwich, tomato soup, and cranberry juice

ANS: C poached eggs would provide highquality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Splitpea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate

Which medication taken at home by a 47year old patient with decreased renal function will be of most concern to the nurse? a.ibuprofen (Motrin) b.warfarin (Coumadin) c.folic acid (vitamin B9) d. penicillin (Bicillin LA)

ANS:A The nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and should be avoided in patients with impaired renal function. The nurse also should ask about reasons the patient is taking the other medications, but the medication of most concern is the ibuprofen.

A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply. A-Ascites B-Hunger C- Pruritus D-Jaundice E-Headache

Ans: A- Ascites, C- Pruritis, D-Jaundice Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common because bile pigments seep into the skin from the bloodstream. Jaundice occurs because the bile duct becomes obstructed and bile enters the bloodstream. The appetite decreases because of the pressure on the abdominal organs from the ascites and the liver's decreased ability to metabolize food. Headache is not a common manifestation of cirrhosis of the liver.

A 48 year old patient s/p right nephrectomy due to trauma from a MVA. What is most important to report to MD? A- Urine output is 20 ML for 2 hours B-Incisional pain is 9/10 C-Fine crackles to right base D-Bp 110/64

Ans: A- Urine output is 20 ML for 2 hours

A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply. A- Butterfly facial rash B-Firm skin fixed to tissue C- Inflammation of the joints D-Muscle mass degeneration E-Inflammation of small arteries

Ans: A-Butterfly facial rash, C-Inflammation of the joints The connective tissue degeneration of SLE leads to involvement of the basal cell layer, producing a butterfly rash over the bridge of the nose and in the cheek region. Polyarthritis occurs in most clients, with joint changes similar to those seen in rheumatoid arthritis. Firm skin fixed to tissue occurs in scleroderma; in an advanced stage the client has the appearance of a living mummy. Muscle mass degeneration occurs in muscular dystrophy; it is characterized by muscle wasting and weakness. Inflammation of small arteries occurs in polyarteritis nodosa, a collagen disease affecting the arteries and nervous system.

Which of the following clinical findings should the nurse expect to find during the assessment of a child with acute glomerulonephritis (AGN)? Select all that apply. a-Flank pain b-Periorbital edema c-Intermittent fever d-Increased urine volume e-Decreased joint mobility

Ans: A-Flank pain, b- Periorbital edema Flank pain is caused by inflammatory and degenerative changes in renal tissue; renal damage occurs because antigen-antibody complexes become trapped in the glomeruli. Because of glomerular dysfunction, filtration of plasma is decreased, causing fluid accumulation and sodium retention; this leads to congestion and edema. Fevers do not occur with AGN. There is usually a decrease, not an increase, in urine volume. Decreased joint mobility does not occur with AGN.

Which manifestations may indicate a client has systemic lupus erythematosus (SLE)? Select all that apply. A-Pericarditis B- Esophagitis C-Fibrotic skin D- Discoid lesion E- Pleural effusions

Ans: A-Pericarditis, D-discoid lesions, E-Pleural effusions SLE is a chronic, progressive inflammatory connective tissue disorder that can cause major organs and systems to fail. Pericarditis is a cardiovascular manifestation of SLE. Discoid lesion is a skin manifestation that is a key indicator of the presence of SLE. Pleural effusion, a pulmonary manifestation, is a key indicator of the presence of SLE. Esophagitis is one of the gastrointestinal manifestations of systemic sclerosis. Fibrotic skin is one of the skin manifestations of systemic sclerosis.

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). Which recommendations are essential for the nurse to include? Select all that apply. A-"Wear a large-brimmed hat." B- "Take your temperature daily." C- "Balance periods of rest and activity." D- "Use a strong soap when washing the skin." E- "Expose the skin to the sun as often as possible."

Ans: A-Wear a large brimmed hat, B-take your temperature daily C-Balance periods of rest and activity A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. SLE can cause alopecia, and hair care recommendations include the use of mild protein shampoos and avoidance of harsh treatments, like permanents or highlights, and use of large-brimmed hat for skin protection. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not recommended. Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? Select all that apply. A-Joint pain B-Facial rash C-Pericarditis D-Weight gain E-Hypotension

Ans: A-joint pain, B-facial rash, C-Pericarditis SLE is a chronic, autoimmune disease that affects connective tissue; joint pain is common. A butterfly rash on the face is characteristic of SLE. Pericarditis is the most common cardiac indicator of SLE. Weight loss, not gain, is a classic sign of SLE because of gastrointestinal effects. Renal impairment with SLE may cause hypertension, not hypotension.

A 19 year old taking azathioprine (Imuran) for SLE has a follow up appt. Which order would the nurse question? A- Naproxen 200 mg by mouth BID B- Administration of MMR vaccine C- Warfarin 5 mg by mouth daily D- Pepcid 20 mg by mouth daily

Ans: B- Administration of MMR vaccine

The nurse is caring for a patient with cirrhosis. What data is of most concern to the nurse? A- Patient C/o right upper quadrant pain w/ palpation B- The patient's hands flap back and forth when arms are extended C-The patient has ascites and a 2 kg weight gain from yesterday D-The patient's abdomen has multiple spider veins.

Ans: B- The patient's hands flap back and forth when arms are extended.

Which result for a patient with SLE is most important for the nurse to communicate to the doctor? A- decreased C-reactive protein B- Elevated Creatinine C-Positive antinuclear antibodies (ANA) D-Positive lupus erythematous cell prep

Ans: B- elevated creatinine

Before administering Captopril to a patient with stage 2 CKD, the nurse will check the patients? A-Glucose B-Potassium C-BUN D-Phosphate

Ans: B- potassium

A nursing intervention to reduce seizures and increased ICP in a patient w/ Meningitis is? A-Administer codeine for relief of head and neck pain B-Control fever with prescribed drugs and cooling techniques C-Keep room dark and quiet to decrease stimulation D-Maintain patient on strict bed rest with head of bed elevated 15 degrees

Ans: B-Control fever with prescribed drugs and cooling techniques

The parents of a 6-year-old child tell a nurse at the pediatric clinic that their child is weak and lethargic, has headaches, has no appetite, and has dark, cloudy urine. The nurse suspects acute poststreptococcal glomerulonephritis (APSGN). What should the nurse ask the mother? a-"Has your child lost weight recently?" b-"Did your child have a sore throat during the past 3 weeks?" c-"Does your child have migratory pains in the shoulders and knees?" d-"Has your child had a rash on the palms and soles in the past 2 weeks?"

Ans: B-Did your child have a sore throat during the past 3 weeks? If the response to the question indicates a recent sore throat, the healthcare provider may decide to prescribe specific tests to confirm a diagnosis of ASPGN. Weight loss usually occurs in children with type 1 diabetes, not glomerulonephritis. This kind of pain is reported in rheumatic fever and scarlet fever, which do not result in the smoky urine associated with hematuria. A rash on the palms and soles is not associated with APSGN.

An adolescent has been admitted with symptoms of fatigue, intermittent fever, weight loss, and arthralgia, and the diagnosis is systemic lupus erythematosus. What is the best intervention at this time? A-Implementation of corticosteroids B-Education about diet, rest, and exercise C-Sun avoidance and calcium supplements D-Avoidance of destructive coping mechanisms

Ans: B-Education about diet, rest, and exercise Client education about the integrative interventions of diet, rest, and exercise will be of the most help to the adolescent client with newly diagnosed lupus. These are interventions that the client has some control over, and this is important to the adolescent. Corticosteroids may not be used until other therapies are unsuccessful. Although sun avoidance and calcium supplements may be helpful, they are not most important. Avoidance of negative coping strategies may be helpful if they are noted, but control over diet, rest, and exercise is a positive coping strategy.

A client is experiencing an exacerbation of systemic lupus erythematosus. To reduce the frequency of exacerbations, what would be important for the nurse to include in the client's teaching plan? A-Basic principles of hygiene B-Techniques to reduce stress C-Measures to improve nutrition D-Signs of an impending exacerbation

Ans: B-techniques to reduce stress Systemic lupus erythematosus is an autoimmune disorder, and physical and emotional stresses have been identified as contributing factors to the occurrence of exacerbations. Although basic principles of hygiene should be performed, inadequate hygiene is not known to produce exacerbations. Although measures to improve nutrition should be done, nutritional status is not significantly correlated to exacerbations. Knowledge of the symptoms will not decrease the occurrence of exacerbations.

A nurse is caring for a child with a tentative diagnosis of acute poststreptococcal glomerulonephritis (APSGN). What test does the nurse expect to be used to confirm the diagnosis? A-Renal biopsy B-Pharyngeal culture C-Antistreptolysin O titer D-Urinary tract sonogram

Ans: C- Antistreptolysin O titer APSGN is a sequela of group A beta-hemolytic streptococcal infection. The antistreptolysin O (ASO) titer is an indication of the presence of circulating serum antibodies to streptococci. A renal biopsy is not performed to confirm APSGN, but it may be employed if a complication arises. A pharyngeal culture may be negative, because APSGN occurs 10 to 21 days after the streptococcal infection. Sonography of the kidneys, ureters, and bladder will not confirm a diagnosis of APSGN.

A 55 year old ESRD is scheduled to receive Epoetin (Procrit) w/ dialysis. The RN should report which of the following? A- Creatinine 4.2 B- o2 sat of 93% C- Hemoglobin level 13 g/dL D- BP 106/60

Ans: C- Hemoglobin level 13 g/dL

The nurse is assessing a patient w/ Bacterial meningitis. Which Sign and symptom would support the diagnosis? A- positive Babinski and paresthesia B- Negative Chvostek's sign and facial tingling C- positive Kernig's sign and nuchal rigidity D- Negative Trousseau's sign and nystagmus

Ans: C- positive kernig's sign and nuchal rigidity

A client is admitted with systemic lupus erythematosus (SLE). The laboratory report shows the presence of neutrophils and monocytes as mediators of injury. Which type of hypersensitivity reaction most likely occurred in the client? A-Type I B-Type II C-Type III D-Type IV

Ans: C- type III Type III hypersensitivity reaction involves immunoglobulin IgG- and IgM-mediated release of neutrophils and monocytes as mediators of injury. It is an immune complex-mediated hypersensitivity reaction that occurs in SLE or rheumatoid arthritis. Allergic rhinitis and asthma may occur when mediators such as histamine and prostaglandins are involved, resulting in a type I hypersensitivity reaction. Type II hypersensitivity reaction is cytotoxic mediated, which occurs in transfusion reaction and Goodpasture syndrome. Type IV hypersensitivity reaction is a delayed hypersensitivity reaction that may occur in contact dermatitis involving T cytotoxic cells.

What is the most appropriate assessment with which to detect the development of complications associated with acute glomerulonephritis (AGN) in a school-aged child? A-Assessing the joints for stiffness daily B-Measuring the pH of each urine specimen C-Checking the blood pressure every 4 hours D-Testing the urine from each voiding for glucose

Ans: C-Checking the blood pressure every 4 hours One characteristic of AGN is hypertension. Arthralgia does not accompany AGN. The pathophysiology of AGN has no effect on the pH of urine. Testing for glycosuria is unnecessary because the kidneys have not lost their ability to reabsorb glucose.

The HCP orders Lactulose 30mL for the pt. w/ cirrhosis. What finding demonstrates the medication is working? A-decrease in albumin B-pt. is stuporous C-decrease in ammonia level D-presence of asterixis

Ans: C-Decrease in ammonia level

A nurse is assessing a school-aged child who has been admitted to the pediatric unit with a diagnosis of acute glomerulonephritis. What clinical finding does the nurse expect? A-Polyuria B-Dehydration C-Periorbital edema D-Decreased blood pressure

Ans: C-Periorbital Edema Decreased filtration of plasma in the glomeruli results in an excess accumulation of fluid and sodium, producing edema that is first evident around the eyes. Oliguria, not polyuria, occurs. There is an excess, not a deficient amount, of body fluid. Hypertension, not hypotension, occurs.

A client with Laënnec cirrhosis has ascites and jaundice and is confused. What is the nursing priority when caring for this client? A-Correcting nutritional deficiencies B-Measuring abdominal girth every day C-Providing for the client's physical safety D-Placing the client in the high-Fowler position

Ans: C-Providing for the clients physical safety Hepatic encephalopathy, related to high ammonia levels, results in central nervous system derangement; physical safety is the priority. Although correcting nutritional deficiencies is important, it is not the priority. Although measuring abdominal girth is important, it is not the priority. The high-Fowler position will be uncomfortable because of the pressure of the distended abdomen against the legs; the semi-Fowler position is more appropriate, and it promotes respiration.

What type of hypersensitivity reaction is the cause of systemic lupus erythematosus? A-Type I B-Type II C-Type III D-Type IV

Ans: C-type III Systemic lupus erythematosus is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I or immediate hypersensitive reaction. Cytotoxic or type II hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions that are caused by delayed or type IV hypersensitivity reactions.

Which focused data will the nurse monitor in a patient with cirrhosis? A-Hemoglobin B-Temperature C-Activity level D-Albumin level

Ans: D- Albumin level

Which finding for a patient admitted with Glomerulonephritis shows that treatment is effective? A- Patient denies pain with voiding B- Urine dipstick is negative for nitrates C- Patient is afebrile D- The peripheral edema is resolved

Ans: D- The peripheral edema is resolved

A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which of these conditions results from this imbalance? a-Hemorrhage with subsequent anemia b-Diminished resistance to bacterial insult c-Malnutrition of cells, especially hepatic cells d-Reduction of colloidal osmotic pressure in the blood

Ans: D-reduction of colloidal osmotic pressure in the blood Albumin is an essential component of the bloodstream that helps maintain both osmotic pressure and fluid and electrolytes. This is not a cause of hemorrhage. Blood components such as platelets, thrombin, and erythrocytes are involved in the prevention of hemorrhage or anemia. Diminished resistance to bacterial insult is not involved directly with immunity and resistance. Blood components, such as T and B lymphocytes, are involved in this process; the liver synthesizes specific proteins intrinsic to the function of antibodies. The serum albumin level is not related to nutrition of cells.

A client reports hair loss, joint pain, and a facial rash. The nurse documents the presence of a butterfly rash on the face in the client's medical record. Which disorder does the nurse suspect? A-Scleroderma B-Angioedema C-Rheumatoid arthritis D-Systemic lupus erythematosus

Ans: Systemic Lupus Erythematosus Systemic lupus erythematosus is an autoimmune connective tissue disorder characterized by joint pain, alopecia, and rashes on the face. A characteristic butterfly rash is a major skin manifestation of systemic lupus erythematosus. Scleroderma is a chronic, inflammatory, autoimmune connective tissue disease characterized by hardening of the skin. Angioedema is the diffuse swelling of the eyes and lips. Rheumatoid arthritis is an inflammatory autoimmune disease process that affects primarily the synovial joints. The primary symptom of rheumatoid arthritis is painful swollen joints.

A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? A-Albumin B-Globulin C-Thrombin D-Hemoglobin

Ans:Globulin The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen.

A patient in the oliguric phase after an acute kidney injury has had a 250 mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient's fluid restriction for the next 24 hours?

ANS: 950 mL The general rule for calculating fluid restrictions is to add all fluid losses for the previous 24 hours, plus 600 mL for insensible losses: (250 + 100 + 600 = 950 mL)

What glomerular filtration rate (GFR) would the nurse estimate for a 30 year old patient with a creatinine clearance result of 60 mL/min? a. 60 mL/min b. 90 mL/min c. 120 mL/min d. 180 mL/min

Ans: A-60 mL/min

A female client asks the nurse if any conditions can exacerbate SLE? Which is the best response? A- Conditions that cause hypotension B-Gastrointestinal upset C-Pregnancy D-Hypertension

Ans: C-Pregnancy

A patient is telling you he took an antibiotic 2 weeks ago and caused him to get C-diff. Which antibiotic is most likely the cause? A- Clindamycin B-Bactrim C-Azithromycin D-Flagyl

Ans: A-Clindamycin

A 55 year old patient develops a massive GI bleed. This patient is at risk for what type of acute kidney injury? A- Post renal B- Intra-renal C- Pre-renal D- Intrinsic renal

Ans: C- pre-renal

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Magnesium hydroxide c. Acetaminophen (Tylenol) d. Calcium phosphate (PhosLo)

ANS: B Magnesium is excreted by the kidneys, and patients with CKD should not use overthe counter products containing magnesium. The other medications are appropriate for a patient with CKD

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). d. level of consciousness (LOC

ANS: A Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse's decision to give the medication

Which action by a 70yearold patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. c. The patient cleans the catheter while taking a bath each day. d. The patient slows the inflow rate when experiencing abdominal pain

ANS: C Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

ANS: B Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate

A 64yearold male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. Unlimited fluids are allowed because retained fluid is removed during dialysis. c. More protein is allowed because urea and creatinine are removed by dialysis. d. Dietary potassium is not restricted because the level is normalized by dialysis

ANS: C Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first ? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Check the medical record for most recent potassium level. d. Check the chart for the patient's current creatinine level

ANS: C The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life threatening dysrhythmias

Which statement is effective from a patient diagnosed with SLE? A-I will exercise even if i am tired B-I will use sunscreen when i am outside C-I should avoid NSAIDS. D-I should take birth control pills to avoid pregnancy

Ans: B- I will use sunscreen when I am outside

A cause of acute glomerulonephritis includes: A-Recent bladder infection B-History of kidney stones C-Recent sore throat and fever D-History of hypertension

Ans: C- Recent sore throat and fever

A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. For which condition is it most important for the nurse to assess this client? A-Nausea B-Blood in the stool C-Food intolerances D-Hourly urinary output

B-Blood in stool Erosion of blood vessels may lead to hemorrhage, a life-threatening situation further complicated by decreased prothrombin production, which occurs with cirrhosis. Although food intolerances should be identified, there is no immediate threat to life. Although increased intraabdominal pressure because of ascites may precipitate nausea, there is no immediate threat to life. Hourly urine output measurements are unnecessary.