The nurse is notified by the cardiac monitoring technician that a patient on continuous
cardiac monitoring is having frequent alarms. When the nurse enters the patient's
room, the patient is in no apparent distress, is sitting in the chair and eating. Which are
appropriate nursing interventions? (Select all that apply)
Call for assistance.
Confirm that lead wires are properly connected.
Assess placement of electrodes.
Remove and reapply new electrodes if nonadherent.
Assess skin sites and move an electrode if the skin appears irritated.
Give this one a try later!
, Confirm that lead wires are properly connected.
Assess placement of electrodes.
Remove and reapply new electrodes if nonadherent.
Assess skin sites and move an electrode if the skin appears irritated.
Rationale: Nursing actions include assessing lead wire connections.
Rationale 2: Nursing actions include assessing placement of electrodes.
Rationale 3: Nursing actions include changing electrodes every 24 to 48
hours or removing and reapplying electrodes that are dislodged or
nonadherent.
Rationale 4: Nursing actions include assessing and documenting skin
condition under the pads and moving pads to alternate sites to avoid skin
irritation.
Rationale 5: Since the patient is in no apparent distress, assistance is not
required.
An older patient is scheduled for a CT scan with and without contrast dye. What
should be done prior to this CT scan?
Monitor renal function.
Assess for level of responsiveness.
Assess vital signs.
Keep the patient NPO.
Give this one a try later!
Monitor renal function.
Rationale: Common nephrotoxins associated with acute tubular necrosis
include radiologic contrast media. The risk for acute tubular necrosis is
higher when nephrotoxic drugs are given to older patients.
, Rationale 2: Monitoring responsiveness is important, but does not address
the specific risks of this examination.
Rationale 3: Monitoring vital signs is important, but does not address the
specific risks of this examination.
Rationale 4: The specific location of the body for the CT scan is not
indicated, therefore, it is not known if the patient would need to be kept
NPO prior to the test.
Upon auscultating the chest of a 75-year-old patient who recently experienced a
myocardial infarction (MI), the nurse hears an S3 and lung crackles. Because of these
findings, the nurse should assess for what other condition?
Extension of the MI
Renal failure
Liver failure
Heart failure
Give this one a try later!
Heart failure
Rationale: S3 and lung crackles are indications of heart failure.
Rationale 2: Manifestations of MI extension include chest pain and a return
of positive laboratory finding (CK-MB and troponin).
Rationale 3: Renal failure is a late complication of heart failure and is not
manifested with an S3 and crackles.
Rationale 4: Liver failure is not manifested with an S3 and crackles.
The nurse administers epoetin alfa (Epogen) to a patient on dialysis. What should the
nurse expect the therapeutic effect of this medication to be?
It treats the anemia seen in chronic kidney disease patients on dialysis.
It combats the effects of dialysis on bone marrow.
, It promotes elimination of nephrotoxic drugs from the body.
It enhances absorption of iron and folate in the intestinal tract.
Give this one a try later!
It treats the anemia seen in chronic kidney disease patients on dialysis.
Rationale: In chronic kidney disease, erythropoietin production in the
kidney declines, which suppresses RBC production leading to anemia.
Erythropoiesis-stimulating agents such as epoetin alfa increase RBC
production.
Rationale 2: Epoetin alfa has no action on bone marrow.
Rationale 3: Epoetin alfa does not promote elimination of nephrotoxic
drugs from the body.
Rationale 4: Epoetin alfa does not affect absorption of iron or folate.
A patient who is recovering from acute kidney injury (AKI) is being discharged. What
should the nurse include in this patient's instructions?
Avoid alcohol consumption.
Use over-the-counter medications as needed.
Instruct to weigh self at least once a month.
Resume a normal diet.
Give this one a try later!
Avoid alcohol consumption.
Rationale: Because alcohol can increase the nephrotoxicity of some drugs,
discourage alcohol ingestion.
Rationale 2: Additional teaching includes avoiding exposure to
nephrotoxins, particularly those found in over-the-counter products.
cardiac monitoring is having frequent alarms. When the nurse enters the patient's
room, the patient is in no apparent distress, is sitting in the chair and eating. Which are
appropriate nursing interventions? (Select all that apply)
Call for assistance.
Confirm that lead wires are properly connected.
Assess placement of electrodes.
Remove and reapply new electrodes if nonadherent.
Assess skin sites and move an electrode if the skin appears irritated.
Give this one a try later!
, Confirm that lead wires are properly connected.
Assess placement of electrodes.
Remove and reapply new electrodes if nonadherent.
Assess skin sites and move an electrode if the skin appears irritated.
Rationale: Nursing actions include assessing lead wire connections.
Rationale 2: Nursing actions include assessing placement of electrodes.
Rationale 3: Nursing actions include changing electrodes every 24 to 48
hours or removing and reapplying electrodes that are dislodged or
nonadherent.
Rationale 4: Nursing actions include assessing and documenting skin
condition under the pads and moving pads to alternate sites to avoid skin
irritation.
Rationale 5: Since the patient is in no apparent distress, assistance is not
required.
An older patient is scheduled for a CT scan with and without contrast dye. What
should be done prior to this CT scan?
Monitor renal function.
Assess for level of responsiveness.
Assess vital signs.
Keep the patient NPO.
Give this one a try later!
Monitor renal function.
Rationale: Common nephrotoxins associated with acute tubular necrosis
include radiologic contrast media. The risk for acute tubular necrosis is
higher when nephrotoxic drugs are given to older patients.
, Rationale 2: Monitoring responsiveness is important, but does not address
the specific risks of this examination.
Rationale 3: Monitoring vital signs is important, but does not address the
specific risks of this examination.
Rationale 4: The specific location of the body for the CT scan is not
indicated, therefore, it is not known if the patient would need to be kept
NPO prior to the test.
Upon auscultating the chest of a 75-year-old patient who recently experienced a
myocardial infarction (MI), the nurse hears an S3 and lung crackles. Because of these
findings, the nurse should assess for what other condition?
Extension of the MI
Renal failure
Liver failure
Heart failure
Give this one a try later!
Heart failure
Rationale: S3 and lung crackles are indications of heart failure.
Rationale 2: Manifestations of MI extension include chest pain and a return
of positive laboratory finding (CK-MB and troponin).
Rationale 3: Renal failure is a late complication of heart failure and is not
manifested with an S3 and crackles.
Rationale 4: Liver failure is not manifested with an S3 and crackles.
The nurse administers epoetin alfa (Epogen) to a patient on dialysis. What should the
nurse expect the therapeutic effect of this medication to be?
It treats the anemia seen in chronic kidney disease patients on dialysis.
It combats the effects of dialysis on bone marrow.
, It promotes elimination of nephrotoxic drugs from the body.
It enhances absorption of iron and folate in the intestinal tract.
Give this one a try later!
It treats the anemia seen in chronic kidney disease patients on dialysis.
Rationale: In chronic kidney disease, erythropoietin production in the
kidney declines, which suppresses RBC production leading to anemia.
Erythropoiesis-stimulating agents such as epoetin alfa increase RBC
production.
Rationale 2: Epoetin alfa has no action on bone marrow.
Rationale 3: Epoetin alfa does not promote elimination of nephrotoxic
drugs from the body.
Rationale 4: Epoetin alfa does not affect absorption of iron or folate.
A patient who is recovering from acute kidney injury (AKI) is being discharged. What
should the nurse include in this patient's instructions?
Avoid alcohol consumption.
Use over-the-counter medications as needed.
Instruct to weigh self at least once a month.
Resume a normal diet.
Give this one a try later!
Avoid alcohol consumption.
Rationale: Because alcohol can increase the nephrotoxicity of some drugs,
discourage alcohol ingestion.
Rationale 2: Additional teaching includes avoiding exposure to
nephrotoxins, particularly those found in over-the-counter products.
