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1. When caring for a client who has just been admitted with septic
shock, which of these assessment data will be of greatest concern
to the nurse?
a. Arterial oxygen saturation 90%
b. Apical pulse 110 beats/min
c. Blood pressure 88/56 mm Hg
d. Urinary output 15 mL for 2 hours - - -
correct answer ✅d. Urinary output 15 mL for 2 hours
2. A client is recovering from a cystoscopy. The nurse would expect
to assess
which of the following regarding the client's urine after the
procedure?
a. Hematuria
b. Blood clots
c. Pink-tinged
d. Anuria - - -
correct answer ✅c. Pink-tinged
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Explanation: The bladder and urethra are usually irritated as a
result of the procedure. This causes pink-tinged urine. Large
amounts of blood in the urine, anuria, or blood clots are not
expected findings after this procedure.
3. A client with congestive heart failure and pulmonary edema
develops early symptoms of acute renal failure (ARF). The nurse
plans care for the client based on the knowledge that collaborative
care of the renal failure will be directed towards which of the
following goals?
a. Diluting nephrotoxic substances
b. Replacing fluid volume
c. Promoting diuresis
d. Maintaining cardiac output - - -
correct answer ✅d. Maintaining cardiac output
Rationale: The primary goal of treatment for ARF is to eliminate the
cause and provide supportive care while the kidneys recover.
Because this patient's heart failure is causing ARF, 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.
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4. Which of the following is the proper positioning for a client
experiencing hypovolemic shock?
a. Trendelenburg
b. Reverse Trendelenburg
c. Supine with head on a pillow
d. Supine with feet elevated - - -
correct answer ✅d. Supine with feet elevated - shock position
5. During discharge teaching for the client with sickle cell anemia,
which of the following precipitating factors for sickle cell crisis
should the nurse instruct the client to avoid?
a. Exposure to crowds
b. Limiting fluids to 2 L per day
c. Excessive dietary iron intake
d. Caffeine and alcohol intake - - -
correct answer ✅a. Exposure to crowds
rationale: Exposure to crowds increases the patient's risk for
infection, the most common cause of sickle cell crisis. There is no
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restriction on caffeine use. Iron supplementation is generally not
recommended. A high-fluid intake is recommended.
6. A client with chronic lymphocytic leukemia is hospitalized for the
treatment of severe hemolytic anemia. Which of the following is an
appropriate nursing intervention for the client?
a. Plan care to alternate periods of rest and activity.
b. Isolate the client from visitors and other clients.
c. Encourage increased intake of fluid and fibre in the diet.
d. Provide a diet high in vitamin K and folic acid. - - -
correct answer ✅a. Plan care to alternate periods of rest and
activity.
Rationale: Nursing care for patients with anemia should alternate
periods of rest and activity to maintain patient mobility without
causing undue fatigue. High vitamin K diets might be used for a
patient with a bleeding disorder. There is no indication that the
patient is neutropenic, so isolation is not needed. Increased intake
of fluid and fiber will not improve the anemia.
7. A client is scheduled for a fistula creation due to end-stage renal
disease. The