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?
a. Remind the patient to take a daily low-dose aspirin tablet.
b. Report the patient's symptoms to the health care provider.
c. Elevate the patient's arm on pillows above the heart level.
d. Teach the patient about normal arteriovenous graft function. - answerANS: 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
Which assessment finding should the nurse expect when a patient with acute kidney
injury
(AKI) has an arterial blood pH of 7.30?
a. Persistent skin tenting
b. Rapid, deep respirations
c. Hot, flushed face and neck
d. Bounding peripheral pulses - answerANS: 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?
, a. Augmenting fluid volume
b. Maintaining cardiac output
c. Diluting nephrotoxic substances
d. Preventing systemic hypertension - answerANS: 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?
a. Urine volume
b. Calcium level
c. Cardiac rhythm
d. Neurologic status - answerANS: 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
effectiveness of the calcium gluconate.
DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that
the
nurse's teaching about management of CKD has been effective?
a. "I need to get most of my protein from low-fat dairy products."
b. "I will increase my intake of fruits and vegetables to 5 per day."
c. "I will measure my output each day to help calculate the amount I can drink."
d. "I need erythropoietin injections to boost my immunity and prevent infection." -
answerANS: C
The patient with end-stage renal disease is taught to measure urine output as a means
of
determining an appropriate oral fluid intake. Erythropoietin is given to increase the red
blood
cell count and will not offer any benefit for immune function. Dairy products are
restricted
because of the high phosphate level. Many fruits and vegetables are high in potassium
and
should be restricted in the patient with CKD.
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?
a. Remind the patient to take a daily low-dose aspirin tablet.
b. Report the patient's symptoms to the health care provider.
c. Elevate the patient's arm on pillows above the heart level.
d. Teach the patient about normal arteriovenous graft function. - answerANS: 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
Which assessment finding should the nurse expect when a patient with acute kidney
injury
(AKI) has an arterial blood pH of 7.30?
a. Persistent skin tenting
b. Rapid, deep respirations
c. Hot, flushed face and neck
d. Bounding peripheral pulses - answerANS: 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?
, a. Augmenting fluid volume
b. Maintaining cardiac output
c. Diluting nephrotoxic substances
d. Preventing systemic hypertension - answerANS: 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?
a. Urine volume
b. Calcium level
c. Cardiac rhythm
d. Neurologic status - answerANS: 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
effectiveness of the calcium gluconate.
DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that
the
nurse's teaching about management of CKD has been effective?
a. "I need to get most of my protein from low-fat dairy products."
b. "I will increase my intake of fruits and vegetables to 5 per day."
c. "I will measure my output each day to help calculate the amount I can drink."
d. "I need erythropoietin injections to boost my immunity and prevent infection." -
answerANS: C
The patient with end-stage renal disease is taught to measure urine output as a means
of
determining an appropriate oral fluid intake. Erythropoietin is given to increase the red
blood
cell count and will not offer any benefit for immune function. Dairy products are
restricted
because of the high phosphate level. Many fruits and vegetables are high in potassium
and
should be restricted in the patient with CKD.
