Exam 3 Iggy Q's 9th edition

Question 1

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer?
a. Epoetin alfa (Epogen)
b. Filgrastim (Neupogen)
c. Mesna (Mesnex)
d. Oprelvekin (Neumega)

Answer 1

A. epogen

Question 2

1. The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client?
   a. Administer the prescribed tetanus toxoid vaccine.
   b. Assess the clients wounds for signs of infection.
   c. Encourage the client to breathe deeply every hour.
   d. Wash your hands on entering the clients room.

Answer 2

D

Question 3

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?
a. Use a disposable blood pressure cuff to avoid sharing with other clients.
b. Change gloves between wound care on different parts of the clients body.
c. Use the closed method of burn wound management for all wound care.
d. Advocate for proper and consistent handwashing by all members of the staff.

Answer 3

B

Question 4

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern?
a. I get my chimney swept every other year.
b. My hot water heater is set at 120 degrees.
c. Sometimes I wake up at night and smoke.
d. I use a space heater when it gets below zero.

Answer 4

C

Question 5

A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond?
a. With reconstructive surgery, you can look the same.
b. We can remove the scars with the use of a pressure dressing.
c. You will not look exactly the same but cosmetic surgery will help.
d. You shouldn’t start worrying about your appearance right now.

Answer 5

C
Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.

Question 6

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance?
a. I will allow my spouse to change my dressings.
b. I want to have surgical reconstruction.
c. I will bathe and dress before breakfast.
d. I have secured the pressure dressings as ordered.

Answer 6

C
Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self- worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

Question 7

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury?
a. It is normal to feel some depression.
b. I will go back to work immediately.
c. I will not feel anger about my situation.
d. Once I get home, things will be normal.

Answer 7

A

Question 8

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first?
a. Apply oxygen and continuous pulse oximetry.
b. Provide small quantities of ice chips and sips of water.
c. Request a prescription for an antitussive medication.
d. Ask the respiratory therapist to provide humidified air.

Answer 8

A. apply oxygen and continuous oximetry

Question 9

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond?
a. Tagamet stimulates intestinal movement so you can eat more.
b. It improves fluid retention, which helps prevent hypovolemic shock.
c. It helps prevent stomach ulcers, which are common after burns.
d. Tagamet protects the kidney from damage caused by dehydration.

Answer 9

C

Question 10

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
a. Assess the level of consciousness and pupillary reactions.
b. Ascertain the time food or liquid was last consumed.
c. Auscultate breath sounds over the trachea and bronchi.
d. Measure abdominal girth and auscultate bowel sounds.

Answer 10

C

Question 11

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?
a. Increase intravenous fluids by 100 mL/hr.
b. Administer furosemide (Lasix) 40 mg IV push.
c. Continue to monitor urine output hourly.
d. Draw blood for serum electrolytes STAT.

Answer 11

B

Question 12

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately?
a. Arterial pH: 7.32
b. Hematocrit: 52%
c. Serum potassium: 6.5 mEq/L
d. Serum sodium: 131 mEq/L

Answer 12

C

Question 13

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next?
a. Administer furosemide (Lasix).
b. Perform chest physiotherapy.
c. Document and reassess in an hour.
d. Place the client in an upright position

Answer 13

D

Question 14

A nurse cares for a client who has burn injuries. The client’s wife asks, When will his high risk for infection decrease? How should the nurse respond?
a. When the antibiotic therapy is complete.
b. As soon as his albumin levels return to normal.
c. Once we complete the fluid resuscitation process.
d. When all of his burn wounds have closed.

Answer 14

D

Question 15

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain?
a. Administer the prescribed intravenous morphine sulfate.
b. Apply ice to skin around the burn wound for 20 minutes.
c. Administer prescribed intramuscular ketorolac (Toradol).
d. Decrease tactile stimulation near the burn injuries.

Answer 15

A

Question 16

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take?
a. Increase the clients oxygen and obtain blood gases.
b. Draw blood for a carboxyhemoglobin level.
c. Increase the clients intravenous fluid rate.
d. Perform a thorough Mini-Mental State Examination.

Answer 16

B

Question 17

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching?
a. You should change the batteries in your smoke detector once a year.
b. Join a program that assists burn clients to reintegration into the community.
c. I will demonstrate how to change your wound dressing for you and your family.
d. Let me tell you about the many options available to you for reconstructive surgery.

Answer 17

C

Question 18

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take?
a. Document the findings and reassess in 1 hour.
b. Loosen any constrictive dressings on the chest.
c. Raise the head of the bed to a semi-Fowlers position.
d. Gather appropriate equipment and prepare for an emergency airway.

Answer 18

D

Question 19

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns?
a. 9%
b. 18%
c. 27%
d. 36%

Answer 19

C

Question 20

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?
a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg
b. Urine output of 20 mL/hr
c. Productive cough with white pulmonary secretions
d. Core temperature of 100.6 F (38 C)

Answer 20

B

Question 21

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity?
a. Keep the water temperature constant when showering the client.
b. Assess the wound beds during the hydrotherapy treatment.
c. Apply a topical enzyme agent after bathing the client.
d. Use sterile saline to irrigate and clean the clients wounds.

Answer 21

A

Question 22

A nurse reviews the following data in the chart of a client with burn injuries:

Wound Assessment
Bilateral leg burns present with a white and leather- like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0- 10.
Based on the data provided, how should the nurse categorize this clients injuries?
a. Partial-thickness deep
b. Partial-thickness superficial
c. Full thickness
d. Superficial

Answer 22

C

The characteristics of the clients wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.

Question 23

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.)
a. Administer analgesics.
b. Prevent wound infections.
c. Provide fluid replacement.
d. Decrease core temperature.
e. Initiate physical therapy.

Answer 23

ANS: A, B, C
Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.

Question 24

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)
a. Music as a distraction
b. Tactile stimulation
c. Massage to injury sites
d. Cold compresses
e. Increasing client control

Answer 24

ANS: A, B, E
Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.

Question 25

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.)
a. Provide at least 5000 kcal/day.
b. Start an oral diet on the first day.
c. Administer a diet high in protein.
d. Collaborate with a registered dietitian.
e. Offer frequent high-calorie snacks.

Answer 25

ANS: A, C, D, E
A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.

Question 26

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.)
a. Slower healing time Increased risk for loss of function from contracture formation
b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure
c. Reduced thoracic compliance Increased risk for atelectasis
d. High incidence of cardiac impairments Increased risk for acute kidney injury
e. Thinner skin May not exhibit a fever when infection is present

Answer 26

ANS: A, C, D
Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.

Question 27

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.)
a. Ask all family members and visitors to perform hand hygiene before touching the client.
b. Carefully monitor burn wounds when providing each dressing change.
c. Clean equipment with alcohol between uses with each client on the unit.
d. Allow family members to only bring the client plants from the hospitals gift shop.
e. Use aseptic technique and wear gloves when performing wound care.

Answer 27

ANS: A, B, E
To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the clients room.

Question 28

A hospitalized client has a platelet count of 58,000/mm3. What action by the nurse is best? a. Encourage high-protein foods.
b. Institute neutropenic precautions.
c. Limit visitors to healthy adults.
d. Place the client on safety precautions.

Answer 28

ANS: D
With a platelet count between 40,000 and 80,000/mm3, clients are at risk of prolonged bleeding even after minor trauma. The nurse should place the client on safety precautions. High-protein foods, while healthy, are not the priority. Neutropenic precautions are not needed as the clients white blood cell count is not low. Limiting visitors would also be more likely related to a low white blood cell count.

Question 29

6. A client is having a bone marrow biopsy today. What action by the nurse takes priority? a. Administer pain medication first.
   b. Ensure valid consent is on the chart.
   c. Have the client shower in the morning.
   d. Premedicate the client with sedatives.

Answer 29

ANS: B
A bone marrow biopsy is an invasive procedure that requires informed consent. Pain medication and sedation are important components of care for this client but do not take priority. The client may or may not need or be able to shower.

Question 30

A nurse is caring for four clients. After reviewing todays laboratory results, which client should the nurse see first?
a. Client with an international normalized ratio of 2.8
b. Client with a platelet count of 128,000/mm3
c. Client with a prothrombin time (PT) of 28 seconds d. Client with a red blood cell count of 5.1 million/L

Answer 30

ANS: C
A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding. The other values are within normal limits.

Question 31

A student nurse learns that the spleen has several functions. What functions do they include? (Select all that apply.)
a. Breaks down hemoglobin
b. Destroys old or defective red blood cells (RBCs)
c. Forms vitamin K for clotting d. Stores extra iron in ferritin
e. Stores platelets not circulating

Answer 31

ANS: A, B, E
Functions of the spleen include breaking down hemoglobin released from RBCs, destroying old or defective RBCs, and storing the platelets that are not in circulation. Forming vitamin K for clotting and storing extra iron in ferritin are functions of the liver.

Question 32

A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best? a. If the WBCs are high, there already is an infection present.
b. The client is in a blast crisis and has too many WBCs.
c. There must be a mistake; the WBCs should be very low.
d. Those WBCs are abnormal and dont provide protection.

Answer 32

ANS: D
In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate.

Question 33

The family of a neutropenic client reports the client is not acting right. What action by the nurse is the priority?
a. Ask the client about pain.
b. Assess the client for infection.
c. Delegate taking a set of vital signs. d. Look at todays laboratory results.

Answer 33

ANS: B
Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse should assess for infection. The nurse should assess for pain but this is not the priority. The nurse should take the clients vital signs instead of delegating them since the client has had a change in status. Laboratory results may be inconclusive.

Question 34

The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met?
a. Doing activities of daily living (ADLs) using rest periods
b. Helping plan a daily activity schedule
c. Requesting a sleeping pill at night
d. Telling visitors to leave when fatigued

Answer 34

ANS: A
Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy.

Question 35

A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important?
a. Preparing to administer a blood transfusion
b. Reinforcing the dressing and documenting findings
c. Removing the dressing and assessing the surgical site
d. Taking a set of vital signs and notifying the surgeon

Answer 35

ANS: D
While some bloody drainage on a new surgical dressing is expected, a saturated dressing is not. This client is already at high risk of bleeding due to the ITP. The nurse should assess vital signs for shock and notify the surgeon immediately. The client may or may not need a transfusion. Reinforcing the dressing is an appropriate action, but the nurse needs to do more than document afterward. Removing the dressing increases the risk of infection; plus, it is not needed since the nurse knows where the bleeding is coming from.

Question 36

A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful?
a. Assist the client to make sick day plans for household responsibilities.
b. Determine if there are family members or friends who can help the client.
c. Help the client inform friends and family that they will have to help out.
d. Refer the client to a social worker in order to investigate respite child care.

Answer 36

ANS: A
While all options are reasonable choices, the best option is to help the client make sick day plans, as that is more comprehensive and inclusive than the other options, which focus on a single item.

Question 37

A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the clients medication list to determine if the client is taking which drug?
a. Enoxaparin (Lovenox)
b. Salicylates (aspirin)
c. Unfractionated heparin d. Warfarin (Coumadin)

Answer 37

ANS: C
This client has manifestations of heparin-induced thrombocytopenia. Enoxaparin, salicylates, and warfarin do not cause this condition.

Question 38

A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.)
a. Chemical exposure
b. Genetically modified foods
c. Ionizing radiation exposure d. Vaccinations
e. Viral infections

Answer 38

ANS: A, C, E
Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

Question 39

A client has Hodgkins lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.)
a. Headaches
b. Night sweats
c. Persistent fever
d. Urinary frequency
e. Weight loss

Answer 39

ANS: B, C, E
In this stage, the disease is located in a single lymph node region or a single nonlymph node site. The client displays night sweats, persistent fever, and weight loss. Headache and urinary problems are not related.

Question 40

A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assist with oral hygiene using a firm toothbrush.
b. Give the client an enema if he or she is constipated.
c. Help the client choose soft foods from the menu.
d. Shave the male client with an electric razor.
e. Use a lift sheet when needed to re-position the client.

Answer 40

ANS: C, D, E
This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a soft- bristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and using a lift sheet to re-position the client.

Question 41

A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.)
a. Azacitidine (Vidaza)
b. Darbepoetin alfa (Aranesp)
c. Decitabine (Dacogen)
d. Epoetin alfa (Epogen)
e. Methylprednisolone (Solu-Medrol)

Answer 41

ANS: B, D
Darbepoetin alfa and epoetin alfa are both red blood cell colony-stimulating factors that will help increase the production of red blood cells. Azacitidine and decitabine are used for myelodysplastic syndromes. Methylprednisolone is a steroid and would not be used for this problem.

Question 42

After teaching a client with hypertension secondary to renal disease, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?
a. I can prevent more damage to my kidneys by managing my blood pressure.
b. If I have increased urination at night, I need to drink less fluid during the day.
c. I need to see the registered dietitian to discuss limiting my protein intake. d. It is important that I take my antihypertensive medications as directed.

Answer 42

ANS: B
The client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions. These clients should be assessed thoroughly for potential dehydration. Increased nocturnal voiding can be decreased by consuming fluids earlier in the day. Blood pressure control is needed to slow the progression of renal dysfunction. When dietary protein is restricted, refer the client to the registered dietitian as needed.

Question 43

The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the clients recent history?
a. Pyelonephritis
b. Myocardial infarction
c. Bladder cancer
d. Kidney stones

Answer 43

ANS: B
Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI related to urine flow obstruction.

Question 44

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurses priority action?
a. Calculate the mean arterial pressure (MAP).
b. Ask for insertion of a pulmonary artery catheter. c. Take the clients pulse.
d. Slow down the normal saline infusion.

Answer 44

ANS: D
The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the clients hemodynamic status, but this should not be the initial action by the nurse. Vital signs are also important after adjusting the intravenous infusion.

Question 45

A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse?
a. Use the catheter for the next laboratory blood draw.
b. Monitor the central venous pressure through this line.
c. Access the line for the next intravenous medication.
d. Place a heparin or heparin/saline dwell after hemodialysis.

Answer 45

ANS: D
The central line should have a heparin or heparin/saline dwell after hemodialysis treatment. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids.

Question 46

The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding?
a. Woman with a blood pressure of 158/90 mm Hg
b. Client with Kussmaul respirations
c. Man with skin itching from head to toe
d. Client with halitosis and stomatitis

Answer 46

ANS: B
Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. Hypertension is common in most clients with CKD, and skin itching increases with calcium-phosphate imbalances, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.

Question 47

The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub?
a. Registered nurse who just floated from the surgical unit
b. Registered nurse who just floated from the dialysis unit
c. Registered nurse who was assigned the same client yesterday
d. Licensed practical nurse with 5 years experience on this floor

Answer 47

C
The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is important to assess subtle differences in clients. Therefore, the registered nurse (RN) who was assigned to this client previously should again give care to this client. The float nurses would not be as knowledgeable about the unit and its clients. The licensed practical nurse may not have the education level of the RN to assess for pericarditis.

Question 48

A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best?
a. Obtain daily weights of the client.
b. Auscultate heart and breath sounds.
c. Palpate the clients abdomen.
d. Assess the clients diet history.

Answer 48

ANS: A
Furosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds should be assessed if there is fluid retention, as in heart failure. Palpation of the clients abdomen is not necessary, but the nurse should check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effect of the medication.

Question 49

A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema?
a. Maintaining oxygen saturation of 89%
b. Minimal crackles and wheezes in lung sounds
c. Maintaining a balanced intake and output
d. Limited shortness of breath upon exertion

Answer 49

ANS: C
With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.

Question 50

A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)?
a. Antibiotic
b. Histamine blocker
c. Bronchodilator
d. Angiotensin-converting enzyme (ACE) inhibitor

Answer 50

ANS: D
ACE inhibitors stop the conversion of angiotensin I to the vasoconstrictor angiotensin II. This category of medication also blocks bradykinin and prostaglandin, increases renin, and decreases aldosterone, which promotes vasodilation and perfusion to the kidney. Antibiotics fight infection, histamine blockers decrease inflammation, and bronchodilators increase the size of the bronchi; none of these medications helps slow the progression of CKD in clients with hypertension.

Question 51

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed?
a. I am thrilled that I can continue to eat fast food.
b. I will cut out bacon with my eggs every morning.
c. My cooking style will change by not adding salt.
d. I will probably lose weight by cutting out potato chips.

Answer 51

ANS: A
Fast food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.

Question 52

A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the clients fluid balance is stable at this time?
a. Decreased calcium levels
b. Increased phosphorus levels
c. No adventitious sounds in the lungs d. Increased edema in the legs

Answer 52

ANS: C
The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the clients body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.

Question 53

A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?
a. Check the clients digoxin (Lanoxin) level.
b. Administer an anti-nausea medication.
c. Ask if the client is able to eat crackers.
d. Get a referral to a gastrointestinal provider.

Answer 53

ANS: A
These signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication. Administering antiemetics, asking if the client can eat, and obtaining a referral to a specialist all address the clients symptoms but do not lead to the cause of the symptoms.

Question 54

The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse?
a. Administer fluid to increase blood pressure.
b. Check the white blood cell count.
c. Monitor the clients temperature.
d. Connect the client to an electrocardiographic (ECG) monitor.

Answer 54

ANS: C
During hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The clients temperature could reflect the temperature of the dialysate. There is no indication to check the white

Question 55

The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse?
a. My sodium level changes by movement from the blood into the dialysate.
b. Dialysis works by movement of wastes from lower to higher concentration.
c. Extra fluid can be pulled from the blood by osmosis.
d. The dialysate is similar to blood but without any toxins.

Answer 55

B
Dialysis works using the passive transfer of toxins by diffusion. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. The other statements show a correct understanding about hemodialysis.

Question 56

A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the clients nose and around the intravenous catheter. What action by the nurse is the priority?
a. Hold pressure over the clients nose for 10 minutes.
b. Take the clients pulse, blood pressure, and temperature.
c. Assess for a bruit or thrill over the arteriovenous fistula.
d. Prepare protamine sulfate for administration.

Answer 56

ANS: D
Heparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the clients system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.

Question 57

A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best?
a. Administer cefazolin since the level of the antibiotic must be maintained.
b. Hold the vitamins but administer the cefazolin.
c. Hold the cefazolin but administer the vitamins.
d. Hold all medications since both cefazolin and vitamins are dialyzable.

Answer 57

ANS: D
Both the cefazolin and the vitamins should be held until after the hemodialysis is completed because they would otherwise be removed by the dialysis process.

Question 58

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?
a. Warm the dialysate solution in a microwave before instillation.
b. Take a sample of the effluent and send to the laboratory.
c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.

Answer 58

ANS: B
An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.

Question 59

A client with chronic kidney disease states, I feel chained to the hemodialysis machine. What is the nurses best response to the clients statement?
a. That feeling will gradually go away as you get used to the treatment.
b. You probably need to see a psychiatrist to see if you are depressed.
c. Do you need help from social services to discuss financial aid?
d. Tell me more about your feelings regarding hemodialysis treatment.

Answer 59

ANS: D
The nurse needs to explore the clients feelings in order to help the client cope and enter a phase of acceptance or resignation. It is common for clients to be discouraged because of the dependency of the treatment, especially during the first year. Referrals to a mental health provider or social services are possibilities, but only after exploring the clients feelings first. Telling the client his or her feelings will go away is dismissive of the clients concerns.

Question 60

A client is recovering from a kidney transplant. The clients urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse?
a. Checking skin turgor
b. Taking blood pressure
c. Assessing lung sounds d. Weighing the client

Answer 60

ANS: B
By taking blood pressure, the nurse is assessing for hypotension that could compromise perfusion to the new kidney. The nurse then should notify the provider immediately. Skin turgor, lung sounds, and weight could give information about the fluid status of the client, but they are not the priority assessment.

Question 61

The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.)
a. I need to decrease sodium, cholesterol, and protein in my diet.
b. My weight should be maintained at a body mass index of 30.
c. Smoking should be stopped as soon as I possibly can.
d. I can continue to take an aspirin every 4 to 8 hours for my pain. e. I really only need to drink a couple of glasses of water each day.

Answer 61

ANS: B, D, E
Weight should be maintained at a body mass index (BMI) of 22 to 25. A BMI of 30 indicates obesity. The use of nonsteroidal anti-inflammatory drugs such as aspirin should be limited to the lowest time at the lowest dose due to interference with kidney blood flow. The client should drink at least 2 liters of water daily. Diet adjustments should be made by restricting sodium, cholesterol, and protein. Smoking causes constriction of blood vessels and decreases kidney perfusion, so the client should stop smoking.

Question 62

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.)
a. I can continue to take antacids to relieve heartburn.
b. I need to ask for an antibiotic when scheduling a dental appointment.
c. Ill need to check my blood sugar often to prevent hypoglycemia.
d. The dose of my pain medication may have to be adjusted.
e. I should watch for bleeding when taking my anticoagulants.

Answer 62

ANS: B, C, D, E
In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).