ACTUAL MED SURG-2 EXAM-Adult II Exam #4 | COMPLETE AND
DETAILED QUESTIONS AND ANSWERS| 55 REAL EXAM QNA | 2025
LATEST UPDATED 100% RATED CORRECT | 100% VERFIED |
ALREADY GRADED A+|GUARANTEED TO PASS!!
A patient has an AV fistula in place in the right upper extremity for hemodialysis
treatments. When planning care for this client, which of the following measures
should the nurse implement to promote client safety?
a. Take blood pressures only in the right arm to ensure safety.
b. Use the fistula for all venipunctures and intravenous infusions
c. Ensure that small clamps are attached to the AV fistula dressing.
d. Assess the fistula for the presence of a bruit and thrill every 4 hours - (answer)d.
AV fistulas are created by an anastamosis of an artery and a vein within the
subcutaneous tissues to create access for hemodialysis. Fistulas should be
evaluated for the presence of thrills (palpate over the area) and bruits (auscultate
with a stethoscope) as an assessment of patency. Blood pressures or venipunctures
are not done on the extremity with the fistula because of the clotting, infection, or
damage to the fistula.
,The home care nurse is making follow-up visits to a client after renal transplant.
The nurse assesses the client for which signs of acute graft rejection?
a. Hypotension, graft tenderness, anemia
b. Hypertension, oliguria, thirst, and hypothermia
c. Fever, hypertension, graft tenderness, and malaise
d. Fever, vomiting, hypotension, and copious amounts of dilute urine output -
(answer)c.
Acute rejection usually occurs within the first 3 months after transplant, although it
can occur for up to 2 years post transplant. The client exhibits fever, hypertension,
malaise, and graft tenderness. Treatment is immediately begun with corticosteroids
and possibly also with monoclonal antibodies and anti lymphocyte agents.
A client is scheduled for computed tomography (CT) of the kidneys to rule out
renal disease. As an essential preprocedure component of the nursing assessment,
the nurse plans to ask the client about a history of:
,a. Allergies
b. Familial renal disease
c. Frequent antibiotic use
d. Long-tern diuretic therapy - (answer)a.
The client undergoing any type of diagnostic testing involving possible dye
administration should be questioned about allergies, specifically an allergy to
shellfish or iodine. This is essential to identify the risk for potential allergic
reaction to contrast dye, which may be used. The other items are also useful as part
of the assessment but are not as critical as the allergy determination in the
preprocedure period.
The nurse assists a client who has a renal disorder collect a 24-hour urine
specimen. Which does the nurse implement to ensure proper collection of the 24-
hour specimen?
a. Have the client void at the start time and discard the specimen.
, b. Strain the specimen before pouring the urine into the container.
c. Save all urine, beginning with the urine voided at the start time.
d. Once completed, refrigerate the urine collection until picked up by the
laboratory. - (answer)a.
The nurse asks the client to void at the beginning of the collection period and
discards this urine sample because the urine has been stored in the bladder for an
undetermined length of time. All urine thereafter is saved in an iced or refrigerated
container. The client is asked to void at the finish time, and this sample is the last
specimen added to the collection. Straining the urine is contraindicated for timed
urine collections. The container is labeled, placed on fresh ice, and send to the
laboratory immediately.
The nurse plans care for a client diagnosed with end stage renal disease (ESRD).
Which findings does the nurse expect to find in the client's medical record? Select
all that apply.
a. edema
DETAILED QUESTIONS AND ANSWERS| 55 REAL EXAM QNA | 2025
LATEST UPDATED 100% RATED CORRECT | 100% VERFIED |
ALREADY GRADED A+|GUARANTEED TO PASS!!
A patient has an AV fistula in place in the right upper extremity for hemodialysis
treatments. When planning care for this client, which of the following measures
should the nurse implement to promote client safety?
a. Take blood pressures only in the right arm to ensure safety.
b. Use the fistula for all venipunctures and intravenous infusions
c. Ensure that small clamps are attached to the AV fistula dressing.
d. Assess the fistula for the presence of a bruit and thrill every 4 hours - (answer)d.
AV fistulas are created by an anastamosis of an artery and a vein within the
subcutaneous tissues to create access for hemodialysis. Fistulas should be
evaluated for the presence of thrills (palpate over the area) and bruits (auscultate
with a stethoscope) as an assessment of patency. Blood pressures or venipunctures
are not done on the extremity with the fistula because of the clotting, infection, or
damage to the fistula.
,The home care nurse is making follow-up visits to a client after renal transplant.
The nurse assesses the client for which signs of acute graft rejection?
a. Hypotension, graft tenderness, anemia
b. Hypertension, oliguria, thirst, and hypothermia
c. Fever, hypertension, graft tenderness, and malaise
d. Fever, vomiting, hypotension, and copious amounts of dilute urine output -
(answer)c.
Acute rejection usually occurs within the first 3 months after transplant, although it
can occur for up to 2 years post transplant. The client exhibits fever, hypertension,
malaise, and graft tenderness. Treatment is immediately begun with corticosteroids
and possibly also with monoclonal antibodies and anti lymphocyte agents.
A client is scheduled for computed tomography (CT) of the kidneys to rule out
renal disease. As an essential preprocedure component of the nursing assessment,
the nurse plans to ask the client about a history of:
,a. Allergies
b. Familial renal disease
c. Frequent antibiotic use
d. Long-tern diuretic therapy - (answer)a.
The client undergoing any type of diagnostic testing involving possible dye
administration should be questioned about allergies, specifically an allergy to
shellfish or iodine. This is essential to identify the risk for potential allergic
reaction to contrast dye, which may be used. The other items are also useful as part
of the assessment but are not as critical as the allergy determination in the
preprocedure period.
The nurse assists a client who has a renal disorder collect a 24-hour urine
specimen. Which does the nurse implement to ensure proper collection of the 24-
hour specimen?
a. Have the client void at the start time and discard the specimen.
, b. Strain the specimen before pouring the urine into the container.
c. Save all urine, beginning with the urine voided at the start time.
d. Once completed, refrigerate the urine collection until picked up by the
laboratory. - (answer)a.
The nurse asks the client to void at the beginning of the collection period and
discards this urine sample because the urine has been stored in the bladder for an
undetermined length of time. All urine thereafter is saved in an iced or refrigerated
container. The client is asked to void at the finish time, and this sample is the last
specimen added to the collection. Straining the urine is contraindicated for timed
urine collections. The container is labeled, placed on fresh ice, and send to the
laboratory immediately.
The nurse plans care for a client diagnosed with end stage renal disease (ESRD).
Which findings does the nurse expect to find in the client's medical record? Select
all that apply.
a. edema
