1
Lewis's Medical Surgical Nursing
11th Edition Harding Test Bank
After the insertion of an arteriovenous graft in the right forearm, a
patient reports pain and
coldness of the right fingers. Which action should the nurse
take?
Remind the patient to take a daily low-dose aspirin tablet.
Report the patient's symptoms to the health care provider.
Elevate the patient's arm on pillows above the heart level.
Teach the patient about normal arteriovenous graft
function. - -Correct answer-ANS: B
The patient's problems suggest the development of distal
ischemia (steal syndrome) and may
require revision of the AVG. Elevating the arm above the heart will
further decrease
perfusion. Pain and coolness are not normal after AVG
insertion. Aspirin therapy is not used
to maintain grafts.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological
Integrity
1
, 2
Which assessment finding should the nurse expect when a patient
with acute kidney injury
(AKI) has an arterial blood pH of 7.30?
Persistent skin tenting
Rapid, deep respirations
Hot, flushed face and neck
Bounding peripheral pulses - -Correct answer-ANS: B
Patients with metabolic acidosis caused by AKI may have
Kussmaul respirations to eliminate
carbon dioxide. Bounding pulses and vasodilation are not
associated with metabolic acidosis.
Because the patient is likely to have fluid retention, poor skin
turgor would not be a finding in
AKI.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological
Integrity
The nurse is planning care for a patient with severe heart failure
who has developed increased
blood urea nitrogen (BUN) and creatinine levels. What will be the
primary treatment goal in
the plan?
Augmenting fluid volume
Maintaining cardiac output
Diluting nephrotoxic substances
2
, 3
Preventing systemic hypertension - -Correct answer-ANS: B
The primary goal of treatment for acute kidney injury (AKI) is to
eliminate the cause and
provide supportive care while the kidneys recover. Because this
patient's heart failure is
causing AKI, the care will be directed toward treatment of the
heart failure. For renal failure
caused by hypertension, hypovolemia, or nephrotoxins, the other
responses could be correct.
DIF: Cognitive Level: Apply (application) TOP: Nursing Process:
Planning
MSC: NCLEX: Physiological Integrity
A patient who has acute glomerulonephritis is hospitalized with
hyperkalemia. Which
information will the nurse monitor to evaluate the effectiveness
of the prescribed calcium
gluconate IV?
Urine volume
Calcium level
Cardiac rhythm
Neurologic status - -Correct answer-ANS: C
The calcium gluconate helps prevent dysrhythmias that might be
caused by the hyperkalemia.
The nurse will monitor the other data as well, but these will not be
helpful in determining the
3
Lewis's Medical Surgical Nursing
11th Edition Harding Test Bank
After the insertion of an arteriovenous graft in the right forearm, a
patient reports pain and
coldness of the right fingers. Which action should the nurse
take?
Remind the patient to take a daily low-dose aspirin tablet.
Report the patient's symptoms to the health care provider.
Elevate the patient's arm on pillows above the heart level.
Teach the patient about normal arteriovenous graft
function. - -Correct answer-ANS: B
The patient's problems suggest the development of distal
ischemia (steal syndrome) and may
require revision of the AVG. Elevating the arm above the heart will
further decrease
perfusion. Pain and coolness are not normal after AVG
insertion. Aspirin therapy is not used
to maintain grafts.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological
Integrity
1
, 2
Which assessment finding should the nurse expect when a patient
with acute kidney injury
(AKI) has an arterial blood pH of 7.30?
Persistent skin tenting
Rapid, deep respirations
Hot, flushed face and neck
Bounding peripheral pulses - -Correct answer-ANS: B
Patients with metabolic acidosis caused by AKI may have
Kussmaul respirations to eliminate
carbon dioxide. Bounding pulses and vasodilation are not
associated with metabolic acidosis.
Because the patient is likely to have fluid retention, poor skin
turgor would not be a finding in
AKI.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological
Integrity
The nurse is planning care for a patient with severe heart failure
who has developed increased
blood urea nitrogen (BUN) and creatinine levels. What will be the
primary treatment goal in
the plan?
Augmenting fluid volume
Maintaining cardiac output
Diluting nephrotoxic substances
2
, 3
Preventing systemic hypertension - -Correct answer-ANS: B
The primary goal of treatment for acute kidney injury (AKI) is to
eliminate the cause and
provide supportive care while the kidneys recover. Because this
patient's heart failure is
causing AKI, the care will be directed toward treatment of the
heart failure. For renal failure
caused by hypertension, hypovolemia, or nephrotoxins, the other
responses could be correct.
DIF: Cognitive Level: Apply (application) TOP: Nursing Process:
Planning
MSC: NCLEX: Physiological Integrity
A patient who has acute glomerulonephritis is hospitalized with
hyperkalemia. Which
information will the nurse monitor to evaluate the effectiveness
of the prescribed calcium
gluconate IV?
Urine volume
Calcium level
Cardiac rhythm
Neurologic status - -Correct answer-ANS: C
The calcium gluconate helps prevent dysrhythmias that might be
caused by the hyperkalemia.
The nurse will monitor the other data as well, but these will not be
helpful in determining the
3
