Exam_1_ID_1052003
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01/06/2023, 09:10 Examsoft | Assessment Builder Exam 1 A client with type 1 diabetes reports recurrent hypoglycemia late in the morning. After collecting the health history what finding should the nurse suspect is most likely causing the late morning hypoglycemia? A. The client likes to nap shortly after eating lunch. v/ B. The client goes to the gym each day before work. C. The client often eats an early lunch, between 11:00 and 11:30. D The client eats oatmeal early in the morning for breakfast. | Rationale: Feedback: Physical exercise changes insulin requirements and may result in a delayed hypoglycemic reaction. Napping after lunch may be a result, not a cause, of hypoglycemia. Similarly, preferring an early lunch may be the client’s response to hypoglycemia but not the cause of it. Eating oatmeal early in the morning would help stabilize blood sugars until later in the morning and would not likely cause hypoglycemia. NAT: Client Needs: Physiological Integrity: Physiological Adaptation The nurse suspects the client with diabetes may be having a hypoglycemic reaction when what manifestation is assessed? A. Unpredictable behaviors \/ B. Diaphoresis C. Flushing of the face D Fruity breath | Rationale: Feedback: Diaphoresis and cool clammy skin are signs of hypoglycemia. Fruity breath accompanies ketoacidosis. Flushing of the face is associated with hyperglycemia. The client’s level of consciousness often changes, but uncharacteristic or unpredictable behaviors do not normally occur. 3 A client asks the nurse what digoxin does to relieve the symptoms of heart failure. What is the nurse’s best response? v/ A. “They make your heart contract more forcefully.” B. “They increase your blood pressure by reducing your urine output.” C. “They increase your heart rate.” D. “They increase the velocity of electrical conduction in your heart.” | Rationale: Feedback: Cardiac glycosides increase intracellular calcium and allow more calcium to enter myocardial cells. This action causes an increased force of myocardial contraction, an increased cardiac output, and renal perfusion that increases urine output. Cardiac glycosides also serve to slow the heart rate and decrease conduction velocity. NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies The nurse assesses a client before administering digoxin. What finding would cause the nurse to withhold the drug and notify the healthcare provider? A. Respiratory rate below 14 B. History revealing liver failure 4 C. Pulse 44 beats/min D Blood pressure 102/66 mm Hg | Rationale: Feedback: Monitor apical pulse for 1 full minute before administering the drug to assess for adverse effects. Hold the dose if the pulse is less than 60 beats/min in an adult or less than 90 beats/min in an infant; retake pulse in 1 hour. If pulse remains low, document pulse, withhold the drug, and notify the prescriber. Moderate hypotension would not likely require withholding the drug. NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies https://ui.examsoft.io/assessments/904918/postings/1052003/builder 1714
01/06/2023, 09:10 Examsoft | Assessment Builder The nurse is caring for a client with heart failure who has been prescribed losartan. What assessment finding would best indicate therapeutic effect? \/ A. The client’s respiratory rate is 19 breaths/min and rales are absent. B. The client’s potassium level rises from 3.7 mmol/L to 5.6 mmol/L. C. The client’s blood pressure changes from 144/93 to 138/90 mm Hg. D. The client’s heart rate changes from 97 to 79 beats/min. | Rationale: ACEls and ARBs both increase potassium levels. NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies The 96-year-old client is receiving digoxin and furosemide. In the morning, the client reports having a headache and feeling nauseated. What should the nurse do first? A. Contact the client’s healthcare provider immediately. v/ B. Check the client’s laboratory values and vital signs. C. Administer acetaminophen and Maalox. D Give the client clear liquids and have the client lie down. | Rationale: Feedback: The nurse will check the client’s digoxin level and electrolytes. Assessing vital signs is important because the risk of cardiac arrhythmias could increase due to the client’s receiving furosemide, which is a potassium-wasting diuretic. The adverse effects most frequently seen with the cardiac glycosides include headache, weakness, drowsiness, and vision changes (a yellow halo around objects is often reported). Gastrointestinal (Gl) upset and anorexia also commonly occur. Only after checking lab values and assessing vital signs might the nurse call the healthcare provider. Acetaminophen and Maalox would not be indicated. Having the client lie down and restricting the diet to clear liquids would be appropriate but not the first actions. NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies What assessment finding indicates that a client’s left-sided heart failure is worsening? A. Increased jugular venous pressure B. Liver enlargement 4 C. Increased crackles in lung fields D Increased pulse rate | Rationale: Feedback: Fluid may accumulate in the lungs due to left-sided heart failure. Clients may evidence dyspnea, tachypnea, and orthopnea. Right-sided failure would include increased jugular venous pressure and liver enlargement. Pulse rate could increase or decrease depending on medications administered. NAT: Client Needs: Physiological Integrity: Physiological Adaptation The nurse expects B-type natriuretic peptide to rise in heart failure because the body is trying to do what? A. Increase blood volume. B. Increase force of cardiac contraction. \/ C. Reduce blood volume and peripheral resistance. D Increase heart rate. | Rationale: Feedback: Human B-type natriuretic peptides are normally produced by myocardial cells as a compensatory response to increased cardiac workload and increased stimulation by the stress hormones. They bind to endothelial cells, leading to dilation and resulting in decreased venous return, peripheral resistance, and cardiac workload. They also suppress the body’s response to the stress hormones, leading to increased fluid loss and further decrease in cardiac workload. Diuretics decrease blood volume, and cardiac glycosides increase force of contraction. NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies https://ui.examsoft.io/assessments/904918/postings/1052003/builder 2/14
01/06/2023, 09:10 Examsoft | Assessment Builder https://ui.examsoft.io/assessments/904918/postings/1052003/builder The nurse is caring for a client with chronic kidney disease whose hemoglobin level is 7.9 mg/dL. What is the nurse’s best action? \/ A. Administer erythropoietin as prescribed. B. Encourage the client’s fluid intake. C. Monitor the client’s intake and output closely. D. Collaborate with the provider to arrange dialysis. | Rationale: When nephrons are lost, as in renal failure, the juxtaglomerular cells that produce erythropoietin are also lost leading to a decrease in red blood cell production and anemia. Dialysis may be necessary, but this will not resolve the client’s anemia. Similarly, pushing fluids will not increase red blood cell production. Fluid balance monitoring is an important aspect of care but will not resolve the client’s anemia. NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE The nurse admits a client to the emergency department and recognizes the client is in diabetic ketoacidosis (DKA) when what 10 manifestations are assessed? Select all that apply. \/ A. Fruity breath B. Edema v/ C. Dehydration D. Agitation \/ E. Slow and deep respirations | Rationale: Feedback: Signs of impending dangerous complications of hyperglycemia such as DKA include the following: fruity breath as the ketones build up in the system and are excreted through the lungs; dehydration as fluid and important electrolytes are lost through the kidneys; slow and deep respirations (Kussmaul respirations) as the body tries to rid itself of high acid levels; loss of orientation and coma rather than agitation are to be expected. Edema is not a sign of DKA. NAT: Client Needs: Physiological Integrity: Physiological Adaptation The nurse is working with a client who has heart failure. What initial compensatory mechanisms will this client’s body be implementing? Select all that apply. \/ A. Increased heart rate Irregular heart rate Increased blood pressure Suppression of the renin—angiotensin—aldosterone system Vv moO O W Increased force of cardiac contraction | Rationale: Feedback: Decreased cardiac output stimulates the baroreceptors in the aortic arch and the carotid arteries, causing a sympathetic stimulation. This sympathetic stimulation causes an increase in heart rate, blood pressure, and rate and depth of respirations, as well as a positive inotropic effect (increased force of contraction) on the heart and an increase in blood volume (through the release of aldosterone). The decrease in cardiac output also stimulates the release of renin from the kidneys and activates the renin—angiotensin— aldosterone system, which further increases blood pressure and blood volume. Irregular heart rate would exacerbate the problem. NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies A student nurse is giving a presentation about the function of antidiuretic hormone and reports that it is released in response 12. to what stimuli? Select all that apply. 4 A. Falling blood volume B. Parasympathetic stimulation v/ C. Rising serum osmolarity D. Rising calcium levels E. Rising parathyroid hormone levels | Rationale: Feedback: Antidiuretic hormone (ADH) is released in response to falling blood volume, sympathetic stimulation, or Rising serum osmolarity. It is not affected by rising calcium or parathyroid levels. NAT: Client Needs: Physiological Integrity: Physiological Adaptation 3/14
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01/06/2023, 09:10 Examsoft | Assessment Builder 3 A 15-year-old male client who has diabetes mellitus type 1 arrives at the emergency department with his mother, who states ' that her son's blood sugar level was 330 mg/dL when he returned from a 3-day baseball camp. The mother administered 8 units of regular insulin subcutaneously an hour ago, but the adolescent progressively became more confused. Initial nursing assessment and findings are listed below. Select the assessment findings that require follow-up by the nurse. A. History of DM type 1 Blood glucose 330 mg/dL Lethargic, but follows commands Pupils equal, reactive to light Heart rate 121 beats per minute AN NN I omMmUoOw® Blood pressure 89/43 mmHg Lung fields clear Voided 100 mL in the last hour | Rationale: The client's mother indicates that the client has diabetes mellitus type 1 and a blood glucose level of 330 mg/dL (18.3 mmol/L), and he has been physically active for 3 days. These statements, in addition to the client's lethargy, alert the nurse to assess for complications of hyperglycemia. Deep rapid respirations, called Kussmaul respirations, are a compensation mechanism that assists the body to exhale additional carbon dioxide to correct acidosis. Without adequate insulin the body is unable to use glucose for energy and begins using stored fat. The breakdown of fat for energy produces ketone bodies. The client's acidic or fruity breath is a sign that the client is metabolizing fat instead of glucose. Although the client is lethargic, his ability to follow simple commands is a positive sign. The client's blood pressure and heart rate indicate that the client is dehydrated. 1 The nurse records the client's weight as 90.4 Ib (41 kg) and implements prescribed care and nursing interventions. Indicate ' whether the nursing actions below are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non- Essential (make no difference or are not necessary) for the client's care at this time. Select the best answer in each row. Nursing Actions Indicated Contraindicated Non-Essential Initiate potassium replacement per hospital protocol. Check the client's blood glucose level hourly. Administer 4 units regular insulin subcutaneously. Help the client drink 120 mL of fruit juice. Check the client's vital signs every 15 minutes. Monitor the client for postural (orthostatic) hypotension. https://ui.examsoft.io/assessments/904918/postings/1052003/builder 4/14
01/06/2023, 09:10 Examsoft | Assessment Builder 15. 16. v/ Vv A 15-year-old male client who has diabetes mellitus type 1 was hospitalized after a 3-day baseball camp with a diagnosis of diabetic ketoacidosis (DKA). The client is alert and oriented and shared his experience at baseball camp with his mother and the nurse, which helped the nurse to identify factors contributing to the client's DKA. After providing health teaching to the client and his mother, the nurse assesses the client's understanding. For each client response, indicate whether the nurse's teaching was Effective (response indicates that the client understands his care), Ineffective (response indicates that the client does not understand his care), or Unrelated (response is not related to the nurse's health teaching). Select the best answer in each row. Prompts Effective Ineffective Unrelated "I will check my blood sugar levels every 4 hours when exercising and playing baseball." "I will hold my long-acting insulin doses when | choose not to take my short- acting insulin doses." "When exercising | will drink only water and not sugar-filled sports drinks." "l will wear protective sports equipment during baseball games and practice." "l will rotate injection sites because scar tissue slows the absorption of insulin administered." "l will contact my mother if my blood sugar level is ever more than 250 mg/dL (13.8 mmol/L)." A client was admitted to the ICU with an acute kidney injury (AKI). Vital signs check every 4 hours was ordered. As the nurse caring for this client, which 3 areas of care need to be implemented and documented regularly? A. Weigh the client daily, regardless of what time of day it is. Measure input and output. If the client is on bed rest, be sure to watch for pressure sores. Check temperature regularly to monitor for signs of infection. Manage fluid and electrolyte balance. mmgo 0w Administer nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control. https://ui.examsoft.io/assessments/904918/postings/1052003/builder 5/14
01/06/2023, 09:10 Examsoft | Assessment Builder https://ui.examsoft.io/assessments/904918/postings/1052003/builder 7 Client comes in for shortness of breath. Client asks if this is related to his heart failure diagnosis, stating, “This happened ' before, but | didn’t have any symptoms.” The nurse recognizes that there are different categories of heart failure. Which assessment findings indicate acute decompensated heart failure in this client? Select all that apply. A. Client is shivering. The client presents with wet-sounding cough. Client not getting dressed due to feeling short of breath. The client feels depressed at times. The client “Woke up trying to catch his breath.” AN NN ® Mmoo O The client requested to remain sitting up. The client admits to forgetfulness. Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal 18. dialysis? Select all that apply. \ A. Avoid commercial salt substitutes. Restrict fluid intake to 1000 mL daily. \/ Report red or brown-colored effluent. Choose high-protein foods for most meals. m OO w Have several servings of dairy products daily. | Rationale: Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is not limited unless weight and blood pressure are not controlled. Dairy products are high in phosphate and usually are limited. The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the 19. 9 health care provider? Vv A. The patient is confused and lethargic. B. The patient was treated for head injury 3 days ago. C. The patient has a urine output of 400 mL/hr. D. The patient’s urine specific gravity is 1.003. | Rationale: The patient’s confusion and lethargy may indicate hypernatremia and should be addressed quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications. MULTIPLE RESPONSE The nurse is planning postoperative care for a patient who is being admitted to the surgical unit from the recovery room after 20. transsphenoidal resection of a pituitary tumor. Which nursing action should be included to check for diabetes insipidus? A. Palpate extremities for edema. Vv B. Measure urine volume every hour. C. Check hematocrit every 8 hours. D Monitor continuous pulse oximetry for 24 hours. | Rationale: After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed. 6/14
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01/06/2023, 09:10 Examsoft | Assessment Builder A 56-yr-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include which of the following? A. elevated hematocrit 4 B. decreased serum sodium C. increased serum chloride D low urine specific gravity | Rationale: When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level. The nurse determines that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic 22. hormone (SIADH) when the patient makes which statement? v/ A. “l need to shop for foods low in sodium and avoid adding salt to food.” B. “l should weigh myself daily and report any sudden weight loss or gain.” C. “I need to limit my fluid intake to no more than the prescribed liquids each day.” D. “l should eat foods high in potassium because diuretics cause potassium loss.” | Rationale: Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred. The nurse determines that desmopressin is effective for a patient with syndrome of inappropriate antidiuretic hormone 23. (SIADH) based on which finding? > weight has increased 4 B. urinary output is increased C. peripheral edema is increased D urine specific gravity is increased | Rationale: Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder. An older adult patient comes to the clinic complaining of frequent, watery stools for the past 3 days. Which action should the 24. nurse take first? A. Obtain the baseline weight. \/ B. Check the patient’s blood pressure. C. Draw blood for serum electrolyte levels. D Ask about extremity numbness or tingling. | Rationale: Because the patient’s history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient’s perfusion status. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 25. 3.0 mEqg/L. The nurse should alert the health care provider immediately that the patient is on which medication? 4 A. Digoxin 0.25 mg/day B. Metoprolol 12.5 mg/day C. Ibuprofen 400 mg every 6 hours D. Lantus insulin 24 U subcutaneously every evening | Rationale: Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level. https://ui.examsoft.io/assessments/904918/postings/1052003/builder 7114
https://ui.examsoft.io/assessments/904918/postings/1052003/builder 01/06/2023, 09:10 Examsoft | Assessment Builder The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum 26. total protein level. Which assessment finding indicates that the patient’s condition has improved? A. Hematocrit 28% B. Absence of skin tenting \/ C. Decreased peripheral edema D. Blood pressure 110/72 mm Hg | Rationale: Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient’s protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to 27. monitor for while the patient is receiving this infusion? Vv A. Lung sounds B. Urinary output C. Peripheral pulses D. Peripheral edema | Rationale: Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation. A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse 28. should take which action? A. Assign the patient to a semi-private room. Vv B. Assign the patient to a room near the nurse’s station. C. Place the patient in a room nearest to the water fountain. D Place the patient anywhere to monitor for constipation/ileus. | Rationale: The patient should be placed near the nurse’s station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. IV potassium chloride (KCIl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the 29. nurse take? A. Administer the KCI as a rapid IV bolus. v/ B. Infuse the KCI at a rate of 10 mEg/hour. C. Only give the KCI through a central venous line. D Discontinue cardiac monitoring during the infusion. | Rationale: IV KCl is administered at a maximal rate of 10 mEqg/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias. 8/14
01/06/2023, 09:10 Examsoft | Assessment Builder Spironolactone is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication 30. has been effective? A. “l'will try to drink at least 8 glasses of water every day.” B. “l will use a salt substitute to decrease my sodium intake.” C. “l'will increase my intake of potassium-containing foods.” 4 D. “l will drink apple juice instead of orange juice for breakfast.” | Rationale: Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium. A patient who is taking hydrochlorothiazide for treatment of hypertension complains of generalized weakness. Which action 1. 3 is appropriate for the nurse to take? A. Assess for facial muscle spasms. B. Ask the patient about loose stools. C. Recommend the patient avoid drinking orange juice with meals. Vv D. Suggest that the health care provider order a basic metabolic panel. | Rationale: Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia. 30 A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The ' nurse should notify the health care provider about which assessment finding? A. Serum hematocrit of 42% Vv B. Serum sodium level of 120 mg/dL C. Reported weight gain of 2.2 |1b (1kQ) D. Urinary output of 280 mL during past 8 hours | Rationale: Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most 33. concern to the nurse? A. Urine output is 30 mL/hr. v/ B. Blood pressure is 86/40 mm Hg. C. Oiral fluid intake is 100 mL for the past 8 hours. D There is prolonged skin tenting over the sternum. | Rationale: The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient’s fluid intake but not as urgently as the hypotension. https://ui.examsoft.io/assessments/904918/postings/1052003/builder 9/14
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01/06/2023, 09:10 Examsoft | Assessment Builder A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-Liter inflows. Which information 34. should the nurse report promptly to the health care provider? A. The patient has an outflow volume of 2000 mL. Vv B. The patient’s peritoneal effluent appears cloudy. C. The patient’s abdomen appears bloated after the inflow. D The patient has abdominal pain during the inflow phase. | Rationale: Cloudy-appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient. 35 A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse ' (RN) to delegate to a dialysis technician? A. Teach the patient about fluid restrictions. \/ B. Check blood pressure before starting dialysis. C. Assess for causes of an increase in predialysis weight. D Determine the ultrafiltration rate for the hemodialysis. | Rationale: Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN. 36 A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. The patient ) has been on fluid restriction during that duration. 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. v/ B. Urine output over an 8-hour period is 2500 mL. C. The blood urea nitrogen (BUN) level is 67 mg/dL. D The glomerular filtration rate is less than 30 mL/min/1.73 m2. | Rationale: 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 72-yr-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated 7. 3 blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? \/ A. Insert urethral catheter. B. Obtain renal ultrasound. C. Draw a complete blood count. D. Infuse normal saline at 30 mL/hour. | Rationale: The patient’s elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate but should be implemented after the retention catheter. https://ui.examsoft.io/assessments/904918/postings/1052003/builder 10/14
01/06/2023, 09:10 Examsoft | Assessment Builder https://ui.examsoft.io/assessments/904918/postings/1052003/builder A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa. Which 38. information should the nurse report to the health care provider before giving the medication? A. Creatinine 1.6 mg/dL B. Oxygen saturation 89% 4 C. Hemoglobin level 17 g/dL D. Blood pressure 98/56 mm Hg | Rationale: High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administered to a target hemoglobin of greater than 12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered. A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin 60 mg IV BID. The nurse will monitor 39. for adverse effects of the medication by evaluating which of the following? A. blood glucose B. urine osmolality 4 C. serum creatinine D serum potassium | Rationale: When a patient at risk for chronic kidney disease (CKD) receives a potentially nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in assessing for the adverse effects of the gentamicin. Before administration of lisinopril for heart failure to a patient with stage 2 chronic kidney disease (CKD), the nurse will check 40. which of the following? A. glucose Vv B. potassium C. creatinine D phosphate | Rationale: Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore careful monitoring of potassium levels is heeded in patients who are at risk for hyperkalemia. The other laboratory values would also be monitored in patients with CKD but would not affect whether the lisinopril was given or not. Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about 4. 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. | Rationale: 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. 11/14
https://ui.examsoft.io/assessments/904918/postings/1052003/builder 01/06/2023, 09:10 Examsoft | Assessment Builder When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to 42. maintain the patency of the fistula? \/ A. Auscultate for a bruit at the fistula site. B. Assess the quality of the left radial pulse. C. Compare blood pressures in the left and right arms. D. Irrigate the fistula site with saline every 8 to 12 hours. | Rationale: The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula. A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? v/ A. A fistula is much less likely to clot. B. A fistula increases patient mobility. C. A fistula can accommodate larger needles. D. A fistula can be used sooner after surgery. | Rationale: Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility. Which lunch menu choice by the patient who is receiving hemodialysis indicates that the nurse’s teaching has been 44, successful? A. Split-pea soup, English muffin, and whole milk B. Oatmeal with cream, a banana, and orange \/ C. Poached eggs, whole-wheat toast, and apple juice D Cheese sandwich, tomato soup, and cranberry juice | Rationale: Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup is high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and cream is high in phosphate. Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, 45. the nurse should ensure that the client has which of the following? 4 A. bowel sounds B. blood glucose C. blood urea nitrogen (BUN) D. level of consciousness (LOC) | Rationale: Administration, either orally or by retention enema, of cation exchange resins (e.g., sodium polystyrene sulfonate) may be necessary. The use of cation exchange resins requires normal bowel function. For instance, cation exchange resins cannot be used if the patient has a paralytic ileus (i.e., absence of peristalsis in the intestine), because intestinal perforation can occur. Sodium polystyrene sulfonate binds with potassium and then is eliminated in the feces. Hinkle 246 12/14
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01/06/2023, 09:10 Examsoft | Assessment Builder 46. Vv Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse’s teaching about management of CKD has been effective? A. “lI need to get most of my protein from low-fat dairy products.” B. “l will increase my intake of fruits and vegetables to 5 per day.” C. “lwill measure my urinary output each day to help calculate the amount | can drink.” D. “lI need to take erythropoietin to boost my immune system and help prevent infection.” | Rationale: The patient with end-stage renal 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. 47. Vv 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 | Rationale: 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. 48. Vv The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary treatment goal in the plan will be which of the following? A. augmenting fluid volume B. maintaining cardiac output C. diluting nephrotoxic substances D. preventing systemic hypertension | Rationale: The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient’s heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct. 49. Vv | Rationale: Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. A. B C. D When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of which? persistent skin tenting rapid, deep respirations hot, flushed face and neck good skin turgor 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. https://ui.examsoft.io/assessments/904918/postings/1052003/builder 13/14
01/06/2023, 09:10 Examsoft | Assessment Builder After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right 00. fingers. Which action should the nurse take? A. Teach the patient about normal AVG function. B. Remind the patient to take a daily low-dose aspirin tablet. \/ C. Report the patient’s symptoms to the health care provider. D Elevate the patient’s arm on pillows to above the heart level. | Rationale: The patient’s complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts. https://ui.examsoft.io/assessments/904918/postings/1052003/builder 14/14