SET WITH DETAILED ANSWER KEY
◉A 4-year old child is hospitalized with a high fever. While the child
is in bed, the child comforts himself by sucking the thumb. The
mother of the child becomes concerned because her child has not
sucked his thumb for 6 months. Which nursing response to the
mother's cocners is most appropriate.. Answer: "This is a form of
developmental regression and can be normal response for a child
who is hospitalized. Continue to love and support your child."
◉A client with kidney failure is at risk for hyperkalemia. The nurse
monitors for which of the following clinical manifestations of
hyperkalemia?. Answer: 1. Muscle weakness
2. Tall T waves on ECG
3. ST depression on ECG
4. Deep tendon hyporflexia
5. Flat P wave on ECG
◉A client with acute kidney injury has a serum potassium level of
6.0 mEq/L. The nurse should plan which action as a priority?.
Answer: Place the client on a cardiac monitor
, ◉A client being hemodialyzed suddenly becomes short of breath
and complains of chest pain. The client is tachycardic, pale, and
anxious and the nurse suspects air embolism. What is the PRIORITY
nursing action?. Answer: Discontinue dialysis and notify the health
care provider (HCP)
◉Which low- potassium foods (less than 400 mg of potassium per
serving) should a nurse plan to include on a list of acceptable foods
for a client experiencing chronic renal failure?. Answer: Cranberry
juice, grapes, fresh string beans, fortified puffed rice cereal
◉After diagnosis of chronic renal failure, a client was started on
epoetin alfa (Epogen). Which finding should a nurse expect when
evaluating the desired theraputic effectiveness of medication?.
Answer: Increase the serum hematocrit (Hct)
◉Which goal should a nurse document as an appropriate outcome
in the plan of care for a client with chronic renal failure?. Answer:
Absence of bleeding
◉The client diagnosed with chronic kidney disease (CKD), and who
has a left forearm graft, is assigned to the nurse and Unlicensed
Assistive Personnel (UAP). Which action by the UAP requires
immediate intervention by the nurse?. Answer: The UAP takes the
BP on the clients left arm