HIT 3 TEST 4 RENAL DISORDERS C 54
EXAM WITH CORRECT QUESTIONS
AND ANSWERS 2025
A nurse identifies a nursing diagnosis of risk for ineffective breathing pattern related
to incisional pain and restricted positioning for a client who has had a nephrectomy.
Which of the following would be most appropriate for the nurse to include in the
client's plan of care? - CORRECT-ANSWERSEncourage use of incentive spirometer
every 2 hours.
Explanation:
To address the issue of ineffective breathing pattern, encouraging the use of incentive
spirometer would be most appropriate to help increase alveolar ventilation.
Administering isotonic fluid therapy would be appropriate for issues involving fluid
loss such as bleeding or hemorrhage. Keeping the drainage catheter below the level of
insertion would be appropriate to reduce the risk of obstruction leading to acute pain.
Monitoring the temperature every 4 hours would be appropriate to reduce the client's
risk for infection.
,The client with chronic renal failure complains of intense itching. Which assessment
finding would indicate the need for further nursing education? - CORRECT-
ANSWERSBrief, hot daily showers
Explanation:
Hot water removes more oils from the skin and can increase dryness and itching.
Tepid water temperature is preferred in the management of pruritus. The use of
moisturizing lotions and creams that do not contain perfumes can be helpful. Avoid
scratching and keeping nails trimmed short is indicated in the management of pruritus.
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on
admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and
creatinine levels are elevated. The physician will most likely write an order for which
treatment? - CORRECT-ANSWERSStart I.V. fluids with a normal saline solution bolus
followed by a maintenance dose.
Explanation:
The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with
a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment
, should rehydrate the client, causing his blood pressure to rise, his urine output to
increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to
tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-
overloaded so his urine output won't increase with furosemide, which would actually
worsen the client's condition. The client doesn't require dialysis because the oliguria
and elevated BUN and creatinine levels are caused by dehydration.
A client who suffered hypovolemic shock during a cardiac incident has developed
acute renal failure. Which is the best nursing rationale for this complication? -
CORRECT-ANSWERSDecrease in the blood flow through the kidneys
Explanation:
Acute renal failure can be caused by poor perfusion and/or decrease in circulating
volume results from hypovolemic shock. Obstruction of urine flow from the kidneys
through blood clot formation and structural damage can result in postrenal disorders
but not indicated in this client.
The nurse weighs a patient daily and measures urinary output every hour. The nurse
notices a weight gain of 1.5 kg in a 74-kg patient over 48 hours. The nurse is aware that
EXAM WITH CORRECT QUESTIONS
AND ANSWERS 2025
A nurse identifies a nursing diagnosis of risk for ineffective breathing pattern related
to incisional pain and restricted positioning for a client who has had a nephrectomy.
Which of the following would be most appropriate for the nurse to include in the
client's plan of care? - CORRECT-ANSWERSEncourage use of incentive spirometer
every 2 hours.
Explanation:
To address the issue of ineffective breathing pattern, encouraging the use of incentive
spirometer would be most appropriate to help increase alveolar ventilation.
Administering isotonic fluid therapy would be appropriate for issues involving fluid
loss such as bleeding or hemorrhage. Keeping the drainage catheter below the level of
insertion would be appropriate to reduce the risk of obstruction leading to acute pain.
Monitoring the temperature every 4 hours would be appropriate to reduce the client's
risk for infection.
,The client with chronic renal failure complains of intense itching. Which assessment
finding would indicate the need for further nursing education? - CORRECT-
ANSWERSBrief, hot daily showers
Explanation:
Hot water removes more oils from the skin and can increase dryness and itching.
Tepid water temperature is preferred in the management of pruritus. The use of
moisturizing lotions and creams that do not contain perfumes can be helpful. Avoid
scratching and keeping nails trimmed short is indicated in the management of pruritus.
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on
admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and
creatinine levels are elevated. The physician will most likely write an order for which
treatment? - CORRECT-ANSWERSStart I.V. fluids with a normal saline solution bolus
followed by a maintenance dose.
Explanation:
The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with
a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment
, should rehydrate the client, causing his blood pressure to rise, his urine output to
increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to
tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-
overloaded so his urine output won't increase with furosemide, which would actually
worsen the client's condition. The client doesn't require dialysis because the oliguria
and elevated BUN and creatinine levels are caused by dehydration.
A client who suffered hypovolemic shock during a cardiac incident has developed
acute renal failure. Which is the best nursing rationale for this complication? -
CORRECT-ANSWERSDecrease in the blood flow through the kidneys
Explanation:
Acute renal failure can be caused by poor perfusion and/or decrease in circulating
volume results from hypovolemic shock. Obstruction of urine flow from the kidneys
through blood clot formation and structural damage can result in postrenal disorders
but not indicated in this client.
The nurse weighs a patient daily and measures urinary output every hour. The nurse
notices a weight gain of 1.5 kg in a 74-kg patient over 48 hours. The nurse is aware that
