Which action can be assigned to the unlicensed assistive personnel (UAP)? ( correct answers )
Measure the client's urinary output.
What is the best initial response by the nurse? ( correct answers ) Describe the location and
type of pain you are having
Based on the nurse's assessment, which assessment data supports the decision to administer
pain medication as the first intervention? (Select all that apply. One, some, or all options may
be correct.) ( correct answers ) Pain rating of 6/10 - Heart rate of 102 beats/minute - Blood
pressure of 132/76 mmHg
Which action should the nurse implement first? ( correct answers ) Administer an
analgesic.
Which interventions are important to include in the client's plan of care while receiving multiple
immunosuppressants? (Select all that apply. One, some, or all options may be correct.)
( correct answers ) Instruct client to wear a mask when walking in the halls. - Instruct visitors
that fresh flowers should not be taken into the room. - Monitor immunosuppression drug levels
regularly.
Which intervention should the nurse ensure is included in the plan of care during
the immediate postoperative period?
a. Monitor Judy's urinary output hourly using an urimeter.
b. Assess Judy's surgical incision every shift.
c. Monitor Judy's nasogastric tube every 4 hours.
d. Encourage Judy to use the incentive spirometer daily. ( correct answers ) a
Which is the priority nursing assessment during the first 24-hour postoperative period? (
correct answers ) Vital signs
The nurse is teaching the patient about fluid management between dialysis treatments. Which
instruction by the nurse is the most accurate? ( correct answers ) Limit fluids in between
treatments to minimize the amount of fluid that needs to be removed during dialysis.
Which expected outcome should be included in the nurse's teaching plan? ( correct answers )
Client will avoid canned and processed foods.
GRADED
A+
,The nurse assesses the dialysis graft. Which assessment should be reported to the healthcare
provider (HCP) immediately? (Select all that apply. One, some, or all options may be correct.) (
correct answers ) Yellow, purulent drainage from graft incision site. - Absence of a thrill over
the graft site. - Capillary refill >10 seconds in the hand where the graft is placed.
Which intervention should the nurse ensure has been include in the client's plan of
care? (Select all that apply. One, some, or all options may be correct.)
A. Instruct lab personnel to obtain blood specimens from the dual-lumen catheter.
B. Perform sterile dressing changes at the dual-lumen catheter site.
C. Empty and record the drainage from the graft tubing regularly.
D. Regularly rotate IV insertion sites above and below the graft site.
E.Assess Judy's distal pulses and circulation in the arm with the access ( correct answers ) B.
Perform sterile dressing changes at the dual lumen catheter site - E. Assess the client's distal
pulses and circulation in the arm with the access.
The nurse documents the assessment of the arteriovenous (AV) graft. Which documentation
best describes a properly functioning AV graft? ( correct answers ) Thrill present and
palpated
The client asks the nurse to clarify what palliative care involves. Which explanation provides the
client the best education regarding palliative care? (Select all that apply. One, some, or all
options may be correct.) ( correct answers ) Palliative care provides relief from symptoms
including pain. - Palliative care supports holistic care and improves quality of life. -
What complication would the client be most concerned about if choosing peritoneal dialysis?
( correct answers ) Abdominal infection/Peritonitis
The nurse prepares and instructs the client for hemodialysis. Which statements by the client
indicate the need for further education? (Select all that apply. One, some, or all options may be
correct.) ( correct answers ) Hemodialysis will help restore kidney function back to a normal
level. - Bowel or bladder perforation may occur with hemodialysis catheter placement.
What action should the nurse take based on the response from the healthcare provider (HCP)
phone call? (Select all that apply. One, some, or all options may be correct.) ( correct answers
) Document both phone calls and the HCP's prescriptions. - Notify the charge nurse and
activate the chain of command - Hold the potassium chloride
Which intervention should the nurse implement? ( correct answers ) Call and speak directly
with the healthcare provider (HCP).
Which intervention is most important for the nurse to implement? ( correct answers ) Hold
the dose of potassium chloride and contact the HCP to report the serum potassium level.
GRADED
A+
,Based on these problems, which nursing intervention should be included in the client's plan
of care? ( correct answers ) Encourage the client to ask questions and discuss fears
about diagnosis
Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa has
been achieved? ( correct answers ) Conjunctival sac returns to a reddish pink color
Which assessment should the nurse perform to determine if the desired outcome of the
losartan has been achieved? ( correct answers ) Blood pressure
Which assessment finding indicates to the nurse that the desired outcome of the calcium
acetate has been achieved? ( correct answers ) Serum phosphorous of 4.0 mg/dL (1.29
mmol/L)5
After the nurse completes the assessment, what findings are most important to report to the
healthcare provider (HCP) ? (Select all that apply. One, some, or all options may be correct.)
( correct answers ) Blood pressure of 178/92 mmHg - Respiratory rate of 28 breaths per
minute- Bibasilar crackles - Edema
The client's hemoglobin level is 7.8 g/dL (78 g/L). What action should the nurse take? ( correct
answers ) Obtain an order to start an erythropoietin stimulating agent (ESA)
What assessment data supports the diagnosis of acute organ rejection? (Select all that apply.
One, some, or all options may be correct.) ( correct answers ) - Blood pressure of 178/96 mm
Hg.
- Sub therapeutic immunosuppression levels
- Acute pain rated 6/10
- Temperature of 100.6 F(38.1 C).
- BUN of 56 mg/dL (19.99 mmol/L)
- Creatinine of 1.9 mg/dL (167.96 mcmol/L
What is the correct interpretation of these ABG's? ( correct answers ) Metabolic acidosis
(compensated)
Which lab value would the nurse be MOST concerned about? ( correct answers ) Glomerular
filtration rate (GFR) of 9mL/min/1.73m2.
The nurse is teaching the client about progression of chronic kidney disease (CKD). Which
evaluation statement documented by the nurse indicates the client's understanding of the
disease process? ( correct answers ) The client acknowledges that renal replacement therapy
will need to be initiated immediately to rid the body of waste and maintain fluid balance.
Based on the client's symptoms, what should the nurse suspect? ( correct answers ) The
client has uremia and may need to start dialysis.
GRADED
A+
, Which additional symptoms should the nurse ask about? (Select all that apply. One, some, or all
options may be correct.) ( correct answers ) - Nausea - Decreased attention span - Itching
The nurse reviews the client's medical history. What part of the medical history should the
nurse consider relevant to the client's current history? (Select all that apply. One, some, or all
options may be correct.) ( correct answers ) - Hypertension - Polycystic kidney disease -
Diabetes Mellitus-
The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings
should the RN document that are consistent with diminished peripheral circulation? (Select all
that apply.)
Diminished hair on legs
Bruising on extremities
Skin cool to touch
Capillary refill less than
3 seconds
Darkened skin on extremities ( correct answers ) Diminished hair on legs
Skin cool to touch
The registered nurse (RN) uses the mini-mental state examination (MMSE) when assessing a
client for admission to an assisted living facility. Which finding is the RN assessing when
requesting the client to count by 7s?
A. Recall of information.
B. Orientation to surroundings.
C. Attention to details.
D. Ability to follow complex commands. ( correct answers ) C
The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which
assessment findings should the RN document that are consistent with diminished peripheral
circulation? (Select all that apply.)
E. Diminished hair on legs.
F. Bruising on extremities.
G. Skin cool to touch.
H. Capillary refill less than 3 seconds.
I. Darkened skin on extremities. ( correct answers ) A, C
Which action should the registered nurse (RN) implement to complete an assessment for a
client while using an interpreter?
J. Ask closed-ended questions with the assistance of the interpreter.
GRADED
A+
Measure the client's urinary output.
What is the best initial response by the nurse? ( correct answers ) Describe the location and
type of pain you are having
Based on the nurse's assessment, which assessment data supports the decision to administer
pain medication as the first intervention? (Select all that apply. One, some, or all options may
be correct.) ( correct answers ) Pain rating of 6/10 - Heart rate of 102 beats/minute - Blood
pressure of 132/76 mmHg
Which action should the nurse implement first? ( correct answers ) Administer an
analgesic.
Which interventions are important to include in the client's plan of care while receiving multiple
immunosuppressants? (Select all that apply. One, some, or all options may be correct.)
( correct answers ) Instruct client to wear a mask when walking in the halls. - Instruct visitors
that fresh flowers should not be taken into the room. - Monitor immunosuppression drug levels
regularly.
Which intervention should the nurse ensure is included in the plan of care during
the immediate postoperative period?
a. Monitor Judy's urinary output hourly using an urimeter.
b. Assess Judy's surgical incision every shift.
c. Monitor Judy's nasogastric tube every 4 hours.
d. Encourage Judy to use the incentive spirometer daily. ( correct answers ) a
Which is the priority nursing assessment during the first 24-hour postoperative period? (
correct answers ) Vital signs
The nurse is teaching the patient about fluid management between dialysis treatments. Which
instruction by the nurse is the most accurate? ( correct answers ) Limit fluids in between
treatments to minimize the amount of fluid that needs to be removed during dialysis.
Which expected outcome should be included in the nurse's teaching plan? ( correct answers )
Client will avoid canned and processed foods.
GRADED
A+
,The nurse assesses the dialysis graft. Which assessment should be reported to the healthcare
provider (HCP) immediately? (Select all that apply. One, some, or all options may be correct.) (
correct answers ) Yellow, purulent drainage from graft incision site. - Absence of a thrill over
the graft site. - Capillary refill >10 seconds in the hand where the graft is placed.
Which intervention should the nurse ensure has been include in the client's plan of
care? (Select all that apply. One, some, or all options may be correct.)
A. Instruct lab personnel to obtain blood specimens from the dual-lumen catheter.
B. Perform sterile dressing changes at the dual-lumen catheter site.
C. Empty and record the drainage from the graft tubing regularly.
D. Regularly rotate IV insertion sites above and below the graft site.
E.Assess Judy's distal pulses and circulation in the arm with the access ( correct answers ) B.
Perform sterile dressing changes at the dual lumen catheter site - E. Assess the client's distal
pulses and circulation in the arm with the access.
The nurse documents the assessment of the arteriovenous (AV) graft. Which documentation
best describes a properly functioning AV graft? ( correct answers ) Thrill present and
palpated
The client asks the nurse to clarify what palliative care involves. Which explanation provides the
client the best education regarding palliative care? (Select all that apply. One, some, or all
options may be correct.) ( correct answers ) Palliative care provides relief from symptoms
including pain. - Palliative care supports holistic care and improves quality of life. -
What complication would the client be most concerned about if choosing peritoneal dialysis?
( correct answers ) Abdominal infection/Peritonitis
The nurse prepares and instructs the client for hemodialysis. Which statements by the client
indicate the need for further education? (Select all that apply. One, some, or all options may be
correct.) ( correct answers ) Hemodialysis will help restore kidney function back to a normal
level. - Bowel or bladder perforation may occur with hemodialysis catheter placement.
What action should the nurse take based on the response from the healthcare provider (HCP)
phone call? (Select all that apply. One, some, or all options may be correct.) ( correct answers
) Document both phone calls and the HCP's prescriptions. - Notify the charge nurse and
activate the chain of command - Hold the potassium chloride
Which intervention should the nurse implement? ( correct answers ) Call and speak directly
with the healthcare provider (HCP).
Which intervention is most important for the nurse to implement? ( correct answers ) Hold
the dose of potassium chloride and contact the HCP to report the serum potassium level.
GRADED
A+
,Based on these problems, which nursing intervention should be included in the client's plan
of care? ( correct answers ) Encourage the client to ask questions and discuss fears
about diagnosis
Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa has
been achieved? ( correct answers ) Conjunctival sac returns to a reddish pink color
Which assessment should the nurse perform to determine if the desired outcome of the
losartan has been achieved? ( correct answers ) Blood pressure
Which assessment finding indicates to the nurse that the desired outcome of the calcium
acetate has been achieved? ( correct answers ) Serum phosphorous of 4.0 mg/dL (1.29
mmol/L)5
After the nurse completes the assessment, what findings are most important to report to the
healthcare provider (HCP) ? (Select all that apply. One, some, or all options may be correct.)
( correct answers ) Blood pressure of 178/92 mmHg - Respiratory rate of 28 breaths per
minute- Bibasilar crackles - Edema
The client's hemoglobin level is 7.8 g/dL (78 g/L). What action should the nurse take? ( correct
answers ) Obtain an order to start an erythropoietin stimulating agent (ESA)
What assessment data supports the diagnosis of acute organ rejection? (Select all that apply.
One, some, or all options may be correct.) ( correct answers ) - Blood pressure of 178/96 mm
Hg.
- Sub therapeutic immunosuppression levels
- Acute pain rated 6/10
- Temperature of 100.6 F(38.1 C).
- BUN of 56 mg/dL (19.99 mmol/L)
- Creatinine of 1.9 mg/dL (167.96 mcmol/L
What is the correct interpretation of these ABG's? ( correct answers ) Metabolic acidosis
(compensated)
Which lab value would the nurse be MOST concerned about? ( correct answers ) Glomerular
filtration rate (GFR) of 9mL/min/1.73m2.
The nurse is teaching the client about progression of chronic kidney disease (CKD). Which
evaluation statement documented by the nurse indicates the client's understanding of the
disease process? ( correct answers ) The client acknowledges that renal replacement therapy
will need to be initiated immediately to rid the body of waste and maintain fluid balance.
Based on the client's symptoms, what should the nurse suspect? ( correct answers ) The
client has uremia and may need to start dialysis.
GRADED
A+
, Which additional symptoms should the nurse ask about? (Select all that apply. One, some, or all
options may be correct.) ( correct answers ) - Nausea - Decreased attention span - Itching
The nurse reviews the client's medical history. What part of the medical history should the
nurse consider relevant to the client's current history? (Select all that apply. One, some, or all
options may be correct.) ( correct answers ) - Hypertension - Polycystic kidney disease -
Diabetes Mellitus-
The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings
should the RN document that are consistent with diminished peripheral circulation? (Select all
that apply.)
Diminished hair on legs
Bruising on extremities
Skin cool to touch
Capillary refill less than
3 seconds
Darkened skin on extremities ( correct answers ) Diminished hair on legs
Skin cool to touch
The registered nurse (RN) uses the mini-mental state examination (MMSE) when assessing a
client for admission to an assisted living facility. Which finding is the RN assessing when
requesting the client to count by 7s?
A. Recall of information.
B. Orientation to surroundings.
C. Attention to details.
D. Ability to follow complex commands. ( correct answers ) C
The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which
assessment findings should the RN document that are consistent with diminished peripheral
circulation? (Select all that apply.)
E. Diminished hair on legs.
F. Bruising on extremities.
G. Skin cool to touch.
H. Capillary refill less than 3 seconds.
I. Darkened skin on extremities. ( correct answers ) A, C
Which action should the registered nurse (RN) implement to complete an assessment for a
client while using an interpreter?
J. Ask closed-ended questions with the assistance of the interpreter.
GRADED
A+
