SAUNDERS NCLEX RN 8TH EDITION EXAM
WITH 100% CORRECT AND VERIFIED
ANSWERS
100% Correct 91
Incorrect 00
Your answers
1 of 91
Term
The nurse has taught the client with polycystic kidney disease about
management of the disorder and prevention and recognition of
complications. The nurse should determine that the client
understands the instructions if the client states that which should be
reported to the primary health care provider (PHCP)? Select all that
apply.
1. Frequent urination
2. Burning on urination
3. A temperature of 100.6º F (38.1º C)
4. New-onset shortness of breath
5. A blood pressure of 105/68 mm Hg
Give this one a try later!
1. Palpation of a thrill over the fistula
The nurse assesses the patency of the fistula by palpating for the presence of a
thrill or auscultating for a bruit. The presence of a thrill and bruit indicate
patency of the fistula. Enlarged visible blood vessels at the fistula site are a
,normal
observation but are not indicative of fistula patency. Although the presence of a
,radial pulse in the left wrist and capillary refill less than 3 seconds in the nail
beds of the fingers on the left hand indicate adequate circulation to the hand,
they do not assess fistula patency.
1. Take no action
Rationale: No action is needed because all of the blood levels are normal for a
hemodialysis client before a treatment. The normal adult ranges of serum
electrolyte levels are sodium 135 to 145 mEq/L (135 to 145 mmol/L), chloride 98
to 106 mEq/L (98 to 106 mmol/L), bicarbonate (venous) 21 to 28 mEq/L (21 to 28
mmol/L), and potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Although the
potassium level is elevated, the normal range for potassium for a client with
chronic kidney disease receiving hemodialysis is 4 to 6.5 mEq/L (4 to 6.5
mmol/L).
1. Frequent urination
2. Burning on urination
3. A temperature of 100.6º F (38.1º C)
4. New-onset shortness of breath
The client with polycystic kidney disease should report any signs and
symptoms of urinary tract infection, such as frequent urination, burning on
urination, and elevated temperature so that treatment may begin
promptly. Lowered blood pressure is not a complication of polycystic
kidney disease, and it is an expected effect of antihypertensive therapy.
The client would be concerned about increases in blood pressure
because control of
hypertension is essential. The client may experience heart failure as a
result of hypertension, and thus any symptoms of heart failure, such as
shortness of breath, are also a concern.
3. "The diuretic phase is characterized by an increase in urine output of about
500 mL in a 24-hour period."
The diuretic phase of acute kidney injury is characterized by an increase in urine
output of more than 1000 mL in a 24-hour period. This increase in urine output
indicates the return of some renal function; however, blood urea nitrogen and
creatinine levels continue to rise during the first few days of diuresis. The diuretic
phase develops about 14 days after the initial insult and lasts about 10 days.
Don't know?
, 2 of 91
Term
A client who has a cold is seen in the emergency department with an
inability to void. Because the client has a history of benign prostatic
hyperplasia, the nurse determines that the client should be
questioned about the use of which medication?
1.Diuretics 2.Antibiotics 3.Antilipemics 4.Decongestants
Give this one a try later!
2. Hypertension
Rationale: AKI caused by glomerulonephritis is classified as intrinsic or intrarenal
failure. This form of AKI commonly manifests with hypertension, tachycardia,
oliguria, lethargy, edema, and other signs of fluid overload. AKI from prerenal
causes is characterized by decreased blood pressure or a recent history of the
same, tachycardia, and decreased cardiac output and central venous pressure.
Bradycardia is not part of the clinical picture for any form of renal failure.
1. Bearing down as if having a bowel movement
The Valsalva maneuver (bearing down) is avoided after prostatectomy because
it increases the risk of bleeding in the postoperative period. An acceptable
exercise is to tighten the abdominal, gluteal, and perineal muscles as if trying
to prevent urination. Another acceptable exercise is to tighten the rectal
sphincter while relaxing the abdominal muscles; this prevents the Valsalva
maneuver from occurring
WITH 100% CORRECT AND VERIFIED
ANSWERS
100% Correct 91
Incorrect 00
Your answers
1 of 91
Term
The nurse has taught the client with polycystic kidney disease about
management of the disorder and prevention and recognition of
complications. The nurse should determine that the client
understands the instructions if the client states that which should be
reported to the primary health care provider (PHCP)? Select all that
apply.
1. Frequent urination
2. Burning on urination
3. A temperature of 100.6º F (38.1º C)
4. New-onset shortness of breath
5. A blood pressure of 105/68 mm Hg
Give this one a try later!
1. Palpation of a thrill over the fistula
The nurse assesses the patency of the fistula by palpating for the presence of a
thrill or auscultating for a bruit. The presence of a thrill and bruit indicate
patency of the fistula. Enlarged visible blood vessels at the fistula site are a
,normal
observation but are not indicative of fistula patency. Although the presence of a
,radial pulse in the left wrist and capillary refill less than 3 seconds in the nail
beds of the fingers on the left hand indicate adequate circulation to the hand,
they do not assess fistula patency.
1. Take no action
Rationale: No action is needed because all of the blood levels are normal for a
hemodialysis client before a treatment. The normal adult ranges of serum
electrolyte levels are sodium 135 to 145 mEq/L (135 to 145 mmol/L), chloride 98
to 106 mEq/L (98 to 106 mmol/L), bicarbonate (venous) 21 to 28 mEq/L (21 to 28
mmol/L), and potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Although the
potassium level is elevated, the normal range for potassium for a client with
chronic kidney disease receiving hemodialysis is 4 to 6.5 mEq/L (4 to 6.5
mmol/L).
1. Frequent urination
2. Burning on urination
3. A temperature of 100.6º F (38.1º C)
4. New-onset shortness of breath
The client with polycystic kidney disease should report any signs and
symptoms of urinary tract infection, such as frequent urination, burning on
urination, and elevated temperature so that treatment may begin
promptly. Lowered blood pressure is not a complication of polycystic
kidney disease, and it is an expected effect of antihypertensive therapy.
The client would be concerned about increases in blood pressure
because control of
hypertension is essential. The client may experience heart failure as a
result of hypertension, and thus any symptoms of heart failure, such as
shortness of breath, are also a concern.
3. "The diuretic phase is characterized by an increase in urine output of about
500 mL in a 24-hour period."
The diuretic phase of acute kidney injury is characterized by an increase in urine
output of more than 1000 mL in a 24-hour period. This increase in urine output
indicates the return of some renal function; however, blood urea nitrogen and
creatinine levels continue to rise during the first few days of diuresis. The diuretic
phase develops about 14 days after the initial insult and lasts about 10 days.
Don't know?
, 2 of 91
Term
A client who has a cold is seen in the emergency department with an
inability to void. Because the client has a history of benign prostatic
hyperplasia, the nurse determines that the client should be
questioned about the use of which medication?
1.Diuretics 2.Antibiotics 3.Antilipemics 4.Decongestants
Give this one a try later!
2. Hypertension
Rationale: AKI caused by glomerulonephritis is classified as intrinsic or intrarenal
failure. This form of AKI commonly manifests with hypertension, tachycardia,
oliguria, lethargy, edema, and other signs of fluid overload. AKI from prerenal
causes is characterized by decreased blood pressure or a recent history of the
same, tachycardia, and decreased cardiac output and central venous pressure.
Bradycardia is not part of the clinical picture for any form of renal failure.
1. Bearing down as if having a bowel movement
The Valsalva maneuver (bearing down) is avoided after prostatectomy because
it increases the risk of bleeding in the postoperative period. An acceptable
exercise is to tighten the abdominal, gluteal, and perineal muscles as if trying
to prevent urination. Another acceptable exercise is to tighten the rectal
sphincter while relaxing the abdominal muscles; this prevents the Valsalva
maneuver from occurring
