Questions and Answers 2024 Version.
Graded A+
A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury.
The client reports diarrhea, a dull headache, palpitations, and muscle tingling and
weakness. Which of the following actions should the nurse take first?
A.
Administer an analgesic to the client
B.
Check the client's electrolyte values
C.
Measure the client's weight
D.
Restrict the client's protein intake -
✔️Correct Answer: B.
Check the client's electrolyte values
The nurse should apply the urgent versus nonurgent priority-setting framework when
caring for the client. Using this framework, the nurse should consider urgent needs to
be the priority because they pose a greater threat to the client. The nurse might also
need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or
nursing knowledge to identify which finding is the most urgent. The nurse should
check the client's most recent potassium value because these findings are
manifestations of hyperkalemia, which can lead to cardiac dysrhythmias.
Incorrect Answers:A. Administering an analgesic for a dull headache is important to
manage the client's pain; however, there is another action that the nurse should take
first.
C. Measuring the client's weight is important to monitor the client's fluid balance;
however, there is another action the nurse should take first.
D. Restricting the client's protein intake is important to manage the client's acute
kidney injury; however, there is another action the nurse should take first.
A nurse is assessing a client who has urolithiasis and reports pain in his thigh. This
finding indicates the stone is in which of the following structures?
A.
Ureter
B.
Bladder
C.
Renal pelvis
D.
Renal tubules -
✔️Correct Answer: A.
Ureter
,When stones are in the ureters, pain radiates to the genitalia and to the thighs.
Incorrect Answers:B. Stones in the bladder produce manifestations of irritation that
resemble a urinary tract infection. They can also cause pain in the vulva and scrotal
areas.
C. The renal pelvis is part of the kidney. Stones in the kidneys cause pain in the
costovertebral region.
D. The renal tubules are within the nephron, which is part of the kidney. Stones in
the kidneys cause flank pain
A nurse is reviewing the laboratory report of a client who has chronic kidney disease
(CKD). The nurse finds the following laboratory test results: potassium 6.8 mEq/L,
calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which finding
is the priority for the nurse to report to the provider?
A.
Hypocalcemia
B.
Hyperkalemia
C.
Anemia
D.
Hypoalbuminemia -
✔️Correct Answer: B.
Hyperkalemia
The nurse should apply the urgent versus nonurgent priority-setting framework when
caring for this client. Using this framework, the nurse should consider urgent needs
the priority need because they pose more of a threat to the client. The nurse may
also need to use Maslow's hierarchy of needs, the ABC priority-setting framework,
and/or nursing knowledge to identify which finding is the most urgent. Hyperkalemia,
which can cause life-threatening cardiac dysrhythmias, is the priority for the nurse to
report to the provider.
Incorrect Answers: A. Hypocalcemia is an expected finding with CKD; therefore,
another finding is the priority for the nurse to report to the provider. The decreased
calcium level would require reporting if the client developed muscle spasms or
twitching.
C. Anemia is an expected finding with CKD; therefore, another finding is the priority
for the nurse to report to the provider.
D. Hyperphosphatemia is an expected finding with CKD; therefore, another finding is
the priority for the nurse to report to the provider.
A nurse is assessing a client who is receiving continuous ambulatory peritoneal
dialysis. Which of the following findings should the nurse report to the provider?
A.
WBC 6,000/mm^3
B.
Potassium 3.0 mEq/L
C.
Clear, pale yellow drainage
D.
Report of abdominal fullness -
, ✔️Correct Answer: B.
Potassium 3.0 mEq/L
A potassium level of 3.0 mEq/L is below the expected reference range and can
cause dysrhythmias. Dialysis removes fluid, waste products, and electrolytes from
the blood and can cause hypokalemia.
Incorrect Answers:A. A WBC count of 6,000/mm^3 is within the expected reference
range.
C. Clear, pale yellow drainage is an expected finding after peritoneal dialysis has
been established.
D. Abdominal fullness is an expected finding during the dwell period, when the
dialysate stays in the peritoneal cavity. A supine low-Fowler's position can reduce
abdominal pressure.
A nurse is assessing a client who is receiving peritoneal dialysis. Which of the
following findings should the nurse report to the provider immediately?
A.
Difficulty draining the effluent
B.
Redness at the access site
C.
Fluid flowing from the catheter site
D.
Cloudy effluent -
✔️Correct Answer: D.
Cloudy effluent
A cloudy or opaque effluent indicates the client is at high risk for peritonitis, a
bacterial infection of the peritoneum. Therefore, this is the priority finding for the
nurse to report to the provider.
Incorrect Answers:A. Difficulty draining the effluent indicates the client is
experiencing clamped tubing, a fibrin clot, or a kinked catheter that is impeding
outflow, which requires further assessment by the nurse. However, another finding is
the priority for the nurse to report.
B. Redness at the access site indicates the client is at risk for local infection, which
can lead to catheter failure and peritonitis. However, another finding is the priority for
the nurse to report.
C. Fluid flowing from the catheter site indicates the client is at risk for dialysate
leakage, which can create a need for hemodialysis support. However, another
finding is the priority for the nurse to report.
A nurse is assessing a client who is postoperative following a transurethral resection
of the prostate (TURP). After the nurse discontinues the client's urinary catheter,
which of the following findings should the nurse report to the provider?
A.
Pink-tinged urine
B.
Report of burning upon urination
C.
Stress incontinence