Exam 2 NR 341
1. The nurse is caring for a client with hypovolemic shock.
The family member asks why the fluids are being warmed.
What is the
Best response by the nurse?
“to prevent complications from hypothermia”
2. The nurse is caring for a newly admitted client diagnosed
with acute kidney injury. The nurse understands that the
acute kidney injury is Most likely related to a history of which
condition?
Sepsis
3. The nurse is caring for a client being monitored by arterial
pressure monitoring. The nurse notes a systolic pressure of
164 mmHg. What action should the nurse take first ?
Assess the client.
4. The nurse is caring for a client with an arteriovenous
(AV) fistula. Upon assessment, the nurse is unable to
auscultate a bruit. What action should the nurse take first?
Notify the provider
5. The nurse is assessing jugular venous pressure. In what
order should the nurse proceed with the steps in the
process? [place the steps in the correct order beginning
with the first step
3.place head of bed between 30-45 degrees.
2. Have client turn head slightly to the left.
6. Shine a pen light across the neck, assess for jugular
venous distension at end of exhalation.
5.observe the highest point of pulsation in the internal
jugular vein at end exhalation.
4. Measure the vertical distance between the pulsation and
the angle of louis.
1. Add 5 cm to the measurement.
, 6. The nurse is caring for a client with acute kidney injury.
The nurse should anticipate which abnormal assessment
finding? BUN/creatinine ratio 25:1
7. The nurse is caring for a client whose vital signs are
monitored using invasive hemodynamic monitoring. Which
action is most important for the nurse to implement to
decrease the risk of infection? Strict hand washing
8. The nurse is preparing a client for placement of a
catheter for arterial pressure monitoring. What is the
best way for the nurse to assess ulnar circulation prior to
catheter insertion?
Occlude the radial artery.
9. The nurse is monitoring a client on hemodialysis. The
nurse understands that which lab value has the highest
potential to be abnormal and cause complications as a
result of fluid imbalance? Electrolytes
10.The nurse is evaluating a client who is being treated
for shock. When evaluating a client being treated for
shock, what finding indicated an improvement in the
client’s condition?
Bun of 12 mg/DL
FOR THE EXAM answer was: Creatinine 2.6mg/dL that’s
too high: normal level is: 0.6 to 1.6mg/dL
11.The nurse is assessing a client during hemodialysis.
Which finding should the nurse report to the health care
provider immediately ? Redness at insertion site
12.When developing the plan of care for an older adult
client with acute kidney injury, the nurse understands
that it is essential to consider which factor in the client’s
history?
Recent use of antibiotics
1. The nurse is caring for a client with hypovolemic shock.
The family member asks why the fluids are being warmed.
What is the
Best response by the nurse?
“to prevent complications from hypothermia”
2. The nurse is caring for a newly admitted client diagnosed
with acute kidney injury. The nurse understands that the
acute kidney injury is Most likely related to a history of which
condition?
Sepsis
3. The nurse is caring for a client being monitored by arterial
pressure monitoring. The nurse notes a systolic pressure of
164 mmHg. What action should the nurse take first ?
Assess the client.
4. The nurse is caring for a client with an arteriovenous
(AV) fistula. Upon assessment, the nurse is unable to
auscultate a bruit. What action should the nurse take first?
Notify the provider
5. The nurse is assessing jugular venous pressure. In what
order should the nurse proceed with the steps in the
process? [place the steps in the correct order beginning
with the first step
3.place head of bed between 30-45 degrees.
2. Have client turn head slightly to the left.
6. Shine a pen light across the neck, assess for jugular
venous distension at end of exhalation.
5.observe the highest point of pulsation in the internal
jugular vein at end exhalation.
4. Measure the vertical distance between the pulsation and
the angle of louis.
1. Add 5 cm to the measurement.
, 6. The nurse is caring for a client with acute kidney injury.
The nurse should anticipate which abnormal assessment
finding? BUN/creatinine ratio 25:1
7. The nurse is caring for a client whose vital signs are
monitored using invasive hemodynamic monitoring. Which
action is most important for the nurse to implement to
decrease the risk of infection? Strict hand washing
8. The nurse is preparing a client for placement of a
catheter for arterial pressure monitoring. What is the
best way for the nurse to assess ulnar circulation prior to
catheter insertion?
Occlude the radial artery.
9. The nurse is monitoring a client on hemodialysis. The
nurse understands that which lab value has the highest
potential to be abnormal and cause complications as a
result of fluid imbalance? Electrolytes
10.The nurse is evaluating a client who is being treated
for shock. When evaluating a client being treated for
shock, what finding indicated an improvement in the
client’s condition?
Bun of 12 mg/DL
FOR THE EXAM answer was: Creatinine 2.6mg/dL that’s
too high: normal level is: 0.6 to 1.6mg/dL
11.The nurse is assessing a client during hemodialysis.
Which finding should the nurse report to the health care
provider immediately ? Redness at insertion site
12.When developing the plan of care for an older adult
client with acute kidney injury, the nurse understands
that it is essential to consider which factor in the client’s
history?
Recent use of antibiotics
