AND ANSWERS | WITH COMPLETE SOLUTION
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 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 Answer - c. Pink-tinged
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 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.
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 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 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 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. 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
nurse would include which of the following in teaching the client about the
fistula?
a. A vein and an artery will be attached surgically.
, b. The fistula can be used 2 to 4 weeks after the surgery for dialysis treatment.
c. The arm should be immobilized for 4 to 6 weeks.
d. One needle will be inserted for each dialysis treatment. Answer - d. One
needle will be inserted for each dialysis treatment
couldn't find on google, seems right though
8. A 12 years old is admitted to the emergency department after being stung by
a
bee. The client's mother tells the nurse that her son has an allergy to bees and
he has been stung before. In what order of priority will the nurse address the
complications?
1. Airway swelling
2. Hypotension
3. Tachypnea
4. Tachycardia
a. 2, 4, 1, 3
b. 1, 2, 3, 4
c. 1, 3 ,2, 4
d. 3, 1, 2, 4 Answer - c. 1, 3 ,2, 4
1. Airway swelling
3. Tachypnea
2. Hypotension
4. Tachycardia