NUR 2502 Multidimensional Care III (MDC 3) Exam 1Questions and Answers

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NUR 2502 Multidimensional Care III (MDC
3) Exam 1Questions and Answers
1. Common assessment findings associated with Chronic Kidney Disease
(CKD) - ANSWER Fatigue, hypertension, peripheral edema, decreased
urine output, and anemia

2. Cause of anemia in Chronic Kidney Disease (CKD) - ANSWER Decreased
production of erythropoietin by the kidneys.

3. Best laboratory indicator of kidney function - ANSWER Serum creatinine

4. Cause of elevated phosphorus levels in CKD - ANSWER Decreased renal
excretion of phosphorus.

5. Most appropriate dietary instruction for advanced CKD - ANSWER Restrict
sodium as prescribed.

6. High-potassium foods commonly restricted in advanced CKD - ANSWER
Bananas, oranges, potatoes, and tomatoes

7. Priority nursing assessment before initiating hemodialysis - ANSWER
Obtain weight and vital signs.

8. Most common complication occurring during hemodialysis - ANSWER
Hypotension

9. Appropriate nursing intervention for an AV fistula - ANSWER Assess for a
bruit and thrill to verify patency.

10.AV fistula assessment finding requiring immediate intervention - ANSWER
Absence of a thrill (indicates occlusion)

11.Nursing actions to protect an AV fistula - ANSWER Avoid blood pressure
measurements/venipunctures in arm, assess daily, avoid restrictive clothing.

12.Importance of daily weights in kidney disease - ANSWER To monitor fluid
retention and volume status.

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13.Client with highest priority/immediate need for dialysis - ANSWER Client
with severe hyperkalemia and ECG changes

14.Maslow's Hierarchy of Needs - ANSWER (level 1) Physiological Needs,
(level 2) Safety and Security, (level 3) Relationships, Love and Affection,
(level 4) Self Esteem, (level 5) Self Actualization

15.Assessment of Comfort Level - ANSWER ask patient if they are
comfortable

16.If they have physcial discomfort, assess level of pain and plan intervention

17.if it's mental discomfort, have them describe the nature of the stress

18.Interventions to prevent impaired comfort - ANSWER anticipate which
patient may experience them and provide preplanned interventions

19.pain - ANSWER 5th vital sign

20.cutaneous pain - ANSWER superficial pain usually involving the skin or
subcutaneous tissue

21.visceral pain - ANSWER pain originating in the internal organs and is non
localized

22.deep somatic pain - ANSWER ligaments, tendons, bones, blood vessels,
nerves

23.radiating pain - ANSWER starts at an origin but spreads to other locations

24.referred pain - ANSWER pain that is felt in a location other than where the
pain originates

25.phantom pain - ANSWER pain or discomfort felt in an amputated limb

26.Assessment of Elimination - ANSWER -take patient history
27.-monitor frequency, amount , and consistency

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28.Interventions to prevent changes in elimination - ANSWER adequate
nutrition and hydration

29.Interventions for patients with changes in elimination - ANSWER -Monitor
pt for signs of fluid and electrolyte imbalance
-adults experiencing urinary incontinence require frequent toileting
-Patients with short term urinary retention require one or more catherization

30.stress incontinence - ANSWER involuntary urine loss with physical strain,
sneezing, or coughing

31.urge incontinence - ANSWER loss of large amounts of urine accompanied
with a strong urge to urinate

32.overflow incontinence - ANSWER small amounts of urine leak from a full
bladder

33.functional incontinence - ANSWER the person has bladder control but
cannot use the toilet in time

34.unconscious incontinence - ANSWER loss of urine when the person does
not realize the bladder is full and has no urge to void

35.intake - ANSWER -measured in mLs
-everything liquid

36.output - ANSWER stools and urine

37.Assessment of Fluid Balance - ANSWER -health hx
-monitor vitals especially pulse rate and quality
-assess skin and mucous membrane for dryness and decreased turgor

38.Interventions to prevent fluid and electrolyte imbalance - ANSWER drink 8
glassess of water a day and eat a balanced diet

39.Interventions for fluid imbalance - ANSWER fluid deficit: replace fluids

40.fluid overload: restrict fluid

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41.Assessment of gas exchange - ANSWER -health hx and assess patients
breathing efforts and pulmonary function test

42.interventions to prevent decreased gas exchange - ANSWER teach infection
control and to stop smoking

43.interventions for someone with decreased gas exchange - ANSWER having
them sit up

44.Assessment of mobility - ANSWER ROM, gait and activity tolerance

45.Interventions to prevent immobility - ANSWER -determine who is at a
higher risk
-teach patients to do ROM every 2 hours
Drinking fluids to prevent DVT
-evaluate need for assitive device

46.Interventions for immobility - ANSWER -passive ROM
-reposition patients every 2 hours
-keep patient skin clean and dry

47.Assessment for sensory perception - ANSWER -conduct a health hx and
determine factors for any sensory loss and perform cranial nerve test

48.Interventions to prevent loss of sensory perception - ANSWER -annual
screening
-use of protective devices

49.Interventions for those with sensory perception loss - ANSWER -encourage
compliance with medications
-use of corrective devices
-visually impaired need guide dogs and those who can't hear need hearing
devices

50.Assessment for Gas exchange - ANSWER -assess RR, O2 sat, breathing
pattern
-collect sputum culture and ABG
-pulmonary function test