The nurse reviews the record of a client diagnosed with acute kidney injury (AKI). It is most
important for the nurseto review which lab value? - ANSWER URINE SPECIFIC GRAVITY
*** specific gravity can indicate fluid volume excess or deficit and is the most important of
the lab values to assess
A client is admitted for dehydration. The nurse observed that the client appears restless and
reports difficulty breathing. The nurse auscultes the client's lungs and hears bilateral basilar
crackles. Which action does the nurse take first? - ANSWER ELEVATE THE HEAD OF THE
BED AND STOP THE iv INFUSION
*** it addresses the clients difficulty breathing and indications of fluid volume overload
A client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow
aspiration biospy. The client says "I am frightened I have never had this test before and I
dont know what to expect." Which statement will the nurse include when responding to the
client's concerns? SATA - ANSWER ***
- "A tight pressure dressing will be placed over the test site after the procedure"
-There is a risk of bleeding so will monitor the test site frequently
BM biopsy - ANSWER - can be done in pt room or treatment room
-pressure dressing applied to reduce rf bleeding
-stinging and discomfort furing biopsy is expected
-monitor for bleeding
1
, -local anesthetic used
A client diagnosed with malnutrition is prescribed continuous enteral feedings through a
newly placed gastrostomy tube. Which action does the nurse include in the client's plan of
care? SATA - ANSWER - rotate the gastrostomy tube 360 degrees once daily
- check for a slight in-and-out movement of the gastrostomy tube
**** 4-8 hrs of enteral feeding should be added to the bag to reduce contamination. The
tube should be rotated 560 daily to reduce skin irritation.
The nurse provides medication intruction to a client who is precribed 60 mcg/hour dose of
transdermal fentanyl every 3 days. Which client statement indicates understanding of the
instructions? - ANSWER "I SHOULD AVOID PLACING A HEATING PAD OVER THE
MEDICATION PATCH"
*** heat source will increse the absorption of med through the skin.
The nurse assess clients for potential spousal abuse. The nurse is most concerned if a client
makes which statement? - ANSWER "ITS MY FAULT BECAUSE I PUSH MY SPOUSE'S
BUTTONS"
*** individuals who expereince spousal abuse often accept blame, become compliant, and
feel helpless
A client diagnosed with rheumatoid arthritis is prescribed 50 mg etanercept subcutaneous
weekly. The client reports joint swelling, symmetrical joint pain, and deformities of both
hands. Which laboratory value does the nruse report the health care provider? -
ANSWER WHITE CELL COUNT 14,000/MM3
***indicative active infection
2
important for the nurseto review which lab value? - ANSWER URINE SPECIFIC GRAVITY
*** specific gravity can indicate fluid volume excess or deficit and is the most important of
the lab values to assess
A client is admitted for dehydration. The nurse observed that the client appears restless and
reports difficulty breathing. The nurse auscultes the client's lungs and hears bilateral basilar
crackles. Which action does the nurse take first? - ANSWER ELEVATE THE HEAD OF THE
BED AND STOP THE iv INFUSION
*** it addresses the clients difficulty breathing and indications of fluid volume overload
A client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow
aspiration biospy. The client says "I am frightened I have never had this test before and I
dont know what to expect." Which statement will the nurse include when responding to the
client's concerns? SATA - ANSWER ***
- "A tight pressure dressing will be placed over the test site after the procedure"
-There is a risk of bleeding so will monitor the test site frequently
BM biopsy - ANSWER - can be done in pt room or treatment room
-pressure dressing applied to reduce rf bleeding
-stinging and discomfort furing biopsy is expected
-monitor for bleeding
1
, -local anesthetic used
A client diagnosed with malnutrition is prescribed continuous enteral feedings through a
newly placed gastrostomy tube. Which action does the nurse include in the client's plan of
care? SATA - ANSWER - rotate the gastrostomy tube 360 degrees once daily
- check for a slight in-and-out movement of the gastrostomy tube
**** 4-8 hrs of enteral feeding should be added to the bag to reduce contamination. The
tube should be rotated 560 daily to reduce skin irritation.
The nurse provides medication intruction to a client who is precribed 60 mcg/hour dose of
transdermal fentanyl every 3 days. Which client statement indicates understanding of the
instructions? - ANSWER "I SHOULD AVOID PLACING A HEATING PAD OVER THE
MEDICATION PATCH"
*** heat source will increse the absorption of med through the skin.
The nurse assess clients for potential spousal abuse. The nurse is most concerned if a client
makes which statement? - ANSWER "ITS MY FAULT BECAUSE I PUSH MY SPOUSE'S
BUTTONS"
*** individuals who expereince spousal abuse often accept blame, become compliant, and
feel helpless
A client diagnosed with rheumatoid arthritis is prescribed 50 mg etanercept subcutaneous
weekly. The client reports joint swelling, symmetrical joint pain, and deformities of both
hands. Which laboratory value does the nruse report the health care provider? -
ANSWER WHITE CELL COUNT 14,000/MM3
***indicative active infection
2
