LA #11 (Urinary) Chapters 47, 48, 49 Flashcards
(164 cards)
1
Q
After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?
a.
Elevate the patient’s arm above the level of the heart.
b.
Report the patient’s symptoms to the health care provider.
c.
Remind the patient about the need to take a daily low-dose aspirin tablet.
d.
Educate the patient about the normal vascular response after AVG insertion.
A
B
The patient’s complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.
2
Q
A patient with acute kidney injury (AKI) has an arterial blood pH of 7.30. The nurse will assess the patient for
a.
vasodilation.
b.
poor skin turgor.
c.
bounding pulses.
d.
rapid respirations.
A
D
Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate 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.
3
Q
A patient with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of
a.
replacing fluid volume.
b.
preventing hypertension.
c.
maintaining cardiac output.
d.
diluting nephrotoxic substances.
A
C
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 would be correct.
4
Q
A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV?
a.
Urine output
b.
Calcium level
c.
Cardiac rhythm
d.
Neurologic status
A
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.
5
Q
A patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which of these orders for the patient will the nurse question?
a.
NPO for 6 hours before IVP procedure
b.
Normal saline 500 mL IV before procedure
c.
Ibuprofen (Advil) 400 mg PO PRN for pain
d.
Dulcolax suppository 4 hours before IVP procedure
A
C
The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the NSAIDs should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure.
6
Q
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 try to get more protein from dairy products.”
b.
“I will try to increase my intake of fruits and vegetables.”
c.
“I will measure my urinary output each day to help calculate the amount I can drink.”
d.
“I need to take the erythropoietin to boost my immune system and help prevent infection.”
A
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.
7
Q
Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?
a.
Blood pressure
b.
Phosphate level
c.
Neurologic status
d.
Creatinine clearance
A
B
Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate.
8
Q
Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the
a.
blood urea nitrogen (BUN) and creatinine.
b.
blood glucose level.
c.
patient’s bowel sounds.
d.
level of consciousness (LOC).
A
C
Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse’s decision to give the medication.
9
Q
The nurse has instructed a patient who is receiving hemodialysis about appropriate dietary choices. Which menu choice by the patient indicates that the teaching has been successful?
a.
Scrambled eggs, English muffin, and apple juice
b.
Oatmeal with cream, half a banana, and herbal tea
c.
Split-pea soup, whole-wheat toast, and nonfat milk
d.
Cheese sandwich, tomato soup, and cranberry juice
A
A
Scrambled eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.
10
Q
Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check the laboratory value for
a.
creatinine.
b.
potassium.
c.
total cholesterol.
d.
serum phosphate.
A
D
If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.
11
Q
Which information will be most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)?
a.
Blood urea nitrogen (BUN) level
b.
Urine output
c.
Creatinine level
d.
Calculated glomerular filtration rate (GFR)
A
D
GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.
12
Q
A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it
a.
is much less likely to clot.
b.
increases patient mobility.
c.
can accommodate larger needles.
d.
can be used sooner after surgery.
A
A
AV fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.
13
Q
When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula?
a.
Check the fistula site for a bruit and thrill.
b.
Assess the rate and quality of the left radial pulse.
c.
Compare blood pressures in the left and right arms.
d.
Irrigate the fistula site with saline every 8 to 12 hours.
A
A
The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.
14
Q
When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching?
a.
Increased calories are needed because glucose is lost during hemodialysis.
b.
Unlimited fluids are allowed since retained fluid is removed during dialysis.
c.
More protein will be allowed because of the removal of urea and creatinine by dialysis.
d.
Dietary sodium and potassium are unrestricted because these levels are normalized by dialysis.
A
C
Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.
15
Q
Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?
a.
The patient slows the inflow rate when experiencing pain.
b.
The patient leaves the catheter exit site without a dressing.
c.
The patient plans 30 to 60 minutes for a dialysate exchange.
d.
The patient cleans the catheter while taking a bath every day.
A
D
Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.
16
Q
When the nurse is taking a history for a patient who is a possible candidate for a kidney transplant, which information about the patient indicates that the patient is not an appropriate candidate for transplantation?
a.
The patient has metastatic lung cancer.
b.
The patient has poorly controlled type 1 diabetes.
c.
The patient has a history of chronic hepatitis C infection.
d.
The patient is infected with the human immunodeficiency virus.
A
A
Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.
17
Q
The nurse is caring for a patient who had kidney transplantation several years ago. Which assessment finding may indicate that the patient is experiencing adverse effects to the prescribed corticosteroid?
a.
Joint pain
b.
Tachycardia
c.
Postural hypotension
d.
Increase in creatinine level
A
A
Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not caused by corticosteroid use.
18
Q
Which data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse?
a.
The blood glucose is 144 mg/dL.
b.
The patient’s blood pressure is 150/92.
c.
There is a nontender lump in the axilla.
d.
The patient has a round, moonlike face.
A
C
A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, moon face, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy.
19
Q
A patient with chronic kidney disease (CKD) brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required?
a.
Multivitamin with iron
b.
Milk of magnesia 30 mL
c.
Calcium phosphate (PhosLo)
d.
Acetaminophen (Tylenol) 650 mg
A
B
Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.
20
Q
A patient with hypertension and stage 2 chronic kidney disease (CKD) is receiving captopril (Capoten). Before administration of the medication, the nurse will check the patient’s
a.
glucose.
b.
potassium.
c.
creatinine.
d.
phosphate.
A
B
Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values also would be monitored in patients with CKD but would not affect whether the captopril was given or not.
21
Q
A new order for IV gentamicin (Garamycin) 60 mg BID is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patient’s
a.
urine osmolality.
b.
serum potassium.
c.
blood glucose level.
d.
blood urea nitrogen (BUN) and creatinine.
A
D
When a patient at risk for chronic kidney disease (CKD) receives a nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in determining the effect of the gentamicin.
22
Q
Which of the following information obtained by the nurse who is caring for a patient with end-stage renal disease (ESRD) indicates the nurse should consult with the health care provider before giving the prescribed epoetin alfa (Procrit)?
a.
Creatinine 1.2 mg/dL
b.
Oxygen saturation 89%
c.
Hemoglobin level 13 g/dL
d.
Blood pressure 98/56 mm Hg
A
C
High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when EPO is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider, but will not affect whether the medication is administered.
23
Q
In a patient with acute kidney injury (AKI) who requires hemodialysis, a temporary vascular access is obtained by placing a catheter in the left femoral vein. Which intervention will be included in the plan of care?
a.
Place the patient on bed rest.
b.
Start continuous pulse oximetry.
c.
Discontinue the retention catheter.
d.
Restrict the patient’s oral protein intake.
A
A
The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.
24
Q
When the nurse is caring for a patient who has been admitted with a severe crushing injury after an industrial accident, which laboratory result will be most important to report to the health care provider?
a.
Serum creatinine level 2.1 mg/dL
b.
Serum potassium level 6.5 mEq/L
c.
White blood cell count 11,500/µL
d.
Blood urea nitrogen (BUN) 56 mg/dL
A
B
The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately. The nurse also will report the other laboratory values, but abnormalities in these are not immediately life threatening.
25
A patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first?
a.
Obtain renal ultrasound.
b.
Insert retention catheter.
c.
Infuse normal saline at 50 mL/hour.
d.
Draw blood for complete blood count.
B
The patient’s elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate, but should be implemented after the retention catheter.
26
Which information about a patient who was admitted 10 days previously with acute kidney injury (AKI) caused by dehydration will be most important for the nurse to report to the health care provider?
a.
The blood urea nitrogen (BUN) level is 67 mg/dL.
b.
The creatinine level is 3.0 mg/dL.
c.
Urine output over an 8-hour period is 2500 mL.
d.
The glomerular filtration rate is \<30 mL/min/1.73m2.
C
The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.
27
After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which action should the nurse take first?
a.
Document the QRS interval.
b.
Notify the patient’s health care provider.
c.
Look at the patient’s current blood urea nitrogen (BUN) and creatinine levels.
d.
Check the chart for the most recent blood potassium level.
D
The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient’s health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval also is appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening bradycardia.
28
When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first?
a.
Insert a urinary retention catheter.
b.
Place the patient on a cardiac monitor.
c.
Administer epoetin alfa (Epogen, Procrit).
d.
Give sodium polystyrene sulfonate (Kayexalate).
B
Since hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output, but does not correct the cause of the renal failure.
29
Which nursing action for a patient who has arrived for a scheduled hemodialysis session is most appropriate for the RN to delegate to a dialysis technician?
a.
Educate patient about fluid restrictions.
b.
Check blood pressure before starting dialysis.
c.
Assess for reasons for increase in predialysis weight.
d.
Determine the ultrafiltration rate for the hemodialysis.
B
Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.
30
The RN observes an LPN/LVN carrying out all of the following actions while caring for a patient with stage 2 chronic kidney disease. Which action requires the RN to intervene?
a.
The LPN/LVN administers erythropoietin subcutaneously.
b.
The LPN/LVN assists the patient to ambulate in the hallway.
c.
The LPN/LVN gives the iron supplement and phosphate binder with lunch.
d.
The LPN/LVN carries a tray containing low-protein foods into the patient’s room.
C
Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency.
31
The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider?
a.
The patient has an outflow volume of 1800 mL.
b.
The patient’s peritoneal effluent appears cloudy.
c.
The patient has abdominal pain during the inflow phase.
d.
The patient complains of feeling bloated after the inflow.
B
Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.
32
Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider?
a.
The urine output is 900 to 1100 mL/hr.
b.
The blood urea nitrogen (BUN) and creatinine levels are elevated.
c.
The patient’s central venous pressure (CVP) is decreased.
d.
The patient has level 8 (on a 10-point scale) incisional pain.
C
The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.
33
A patient in the oliguric phase of acute renal failure has a 24-hour fluid output of 150 mL emesis and 250 mL urine. The nurse plans a fluid replacement for the following day of ___ mL.
a.
400
b.
800
c.
1000
d.
1400
C
Usually fluid replacement should be based on the patient’s measured output plus 600 mL/day for insensible losses.
34
During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first?
a.
Slow down the rate of dialysis.
b.
Obtain blood to check the blood urea nitrogen (BUN) level.
c.
Check the patient’s blood pressure.
d.
Give prescribed PRN antiemetic drugs.
C
The patient’s complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions also may be appropriate, based on the blood pressure obtained.
35
Which parameter will be most important for the nurse to consider when titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation?
a.
Heart rate
b.
Blood urea nitrogen (BUN) level
c.
Urine output
d.
Creatinine clearance
C
Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.
36
A patient complains of leg cramps during hemodialysis. The nurse should first
a.
reposition the patient.
b.
massage the patient’s legs.
c.
give acetaminophen (Tylenol).
d.
infuse a bolus of normal saline.
D
Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.
37
Which of the following assessment findings would the nurse expect in the patient with a lower urinary tract infection (UTI)?
a.
Flank pain
b.
Dysuria
c.
Oliguria
d.
Nausea
B
Pain with urination is a common symptom of a lower UTI. Urinary output does not decrease, but frequency may be experienced.
38
What is one of the most important ways to prevent the development of acute post-streptococcal glomerulonephritis?
a.
Control of blood pressure with exercise
b.
Early diagnosis and treatment of sore throat
c.
Ensuring complete bladder emptying when the patient voids
d.
Daily intake of high-potency multivitamins
B
One of the most important ways to prevent the development of acute post-streptococcal glomerulonephritis is to encourage early diagnosis and treatment of sore throats and skin lesions.
39
The nurse determines that instruction regarding prevention of future UTIs for a patient with cystitis has been effective when the patient gives which of the following responses?
a.
“I will limit my fluid intake to 1000 mL/day to prevent symptoms of frequency and urgency.”
b.
“I will increase my fluid intake and empty my bladder every 2 to 4 hours during waking hours.”
c.
“I should use an antiseptic vaginal deodorant spray twice a day to reduce the bacterial growth in the perineal area.”
d.
“I will wash my perineal area with soap and water after each bowel movement and before and after sexual intercourse.”
B
Voiding every 2 to 4 hours is recommended to prevent UTIs.
40
To relieve the symptoms of a lower UTI for which the patient is taking prescribed antibiotics, the nurse suggests that the patient use the over-the-counter urinary analgesic of phenazopyridine (Pyridium), but should give the patient which of the following cautions?
a.
This preparation contains methylene blue, which turns the urine blue or green.
b.
This preparation must be taken with food to prevent gastrointestinal irritation.
c.
This preparation causes the urine to turn reddish orange and can stain underclothing.
d.
This preparation frequently causes allergic reactions and should be stopped if a rash occurs.
C
Patients should be taught that phenazopyridine will colour the urine deep orange and stain underclothing.
41
A 34-year-old patient with diabetes mellitus is hospitalized with fever, anorexia, and confusion. The physician suspects acute pyelonephritis when the urinalysis reveals bacteriuria. Which of the following is an appropriate collaborative problem identified by the nurse for this patient?
a.
Potential complication: urosepsis
b.
Potential complication: hydronephrosis
c.
Potential complication: acute kidney injury
d.
Potential complication: chronic pyelonephritis
A
Infection can easily spread from the kidney to the circulation, causing urosepsis.
42
A 72-year-old man has benign prostatic hypertrophy, which has contributed to repeated bouts of cystitis. He is now admitted to the hospital with chills, fever, and nausea and vomiting. A urinalysis is positive for bacteria, red blood cells, and white blood cells. The nurse suspects the presence of an upper UTI when assessment of the patient reveals which of the following findings?
a.
Suprapubic pain
b.
Foul-smelling urine
c.
A distended bladder
d.
Costovertebral angle (CVA) tenderness
D
CVA tenderness is characteristic of pyelonephritis.
43
After teaching a patient with interstitial cystitis about management of the condition, the nurse determines that further instruction is needed when the patient makes which of the following comments?
a.
“I will avoid eating citrus products and aged cheese.”
b.
“I should take a high-potency multivitamin daily.”
c.
“I should report the development of bladder pain or odorous urine.”
d.
“I can use the dietary supplement calcium glycerophosphate (Prelief) to control my symptoms.”
B
High-potency multivitamins may irritate the bladder and increase symptoms.
44
When admitting a patient with acute glomerulonephritis, the nurse inquires about which of the following?
a.
History of high blood pressure
b.
Frequency of UTIs
c.
Recent sore throat and fever
d.
Family history of kidney disease
C
Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat, so it is appropriate for the nurse to ask about recent sore throat and fever.
45
The nurse establishes a nursing diagnosis of excess fluid volume related to decreased glomerular filtration rate in a patient with acute post-streptococcal glomerulonephritis. Which of the following clinical data support this nursing diagnosis?
a.
Proteinuria
b.
Elevated blood urea nitrogen
c.
Periorbital edema
d.
Hematuria with smoky urine
C
Resolution of the excess fluid volume is best evaluated by changes in edema.
46
A patient with nephrotic syndrome develops flank pain. The nurse will anticipate treatment with which of the following?
a.
Antibiotics
b.
Antihypertensives
c.
Anticoagulants
d.
Corticosteroids
C
Flank pain in a patient with nephrosis suggests a renal vein thrombosis, and anticoagulation is needed.
47
One week after using an over-the-counter nonsteroidal anti-inflammatory drug to treat aches resulting from a fall, a patient noticed the development of progressive edema throughout his body. Diagnostic studies confirmed a diagnosis of nephrotic syndrome. When teaching the patient about his condition, the nurse uses the knowledge that the edema results from which of the following changes?
a.
Increased serum oncotic pressure exerted by dyslipidemia
b.
Loss of protein through the kidney, resulting in a fall in plasma colloid osmotic pressure
c.
Loss of albumin in the urine, creating an osmotic diuresis and low tissue hydrostatic pressure
d.
Fluid retention caused by decreased glomerular filtration rate through kidneys damaged by trauma
B
The increased glomerular membrane permeability found in nephrotic syndrome is responsible for the massive excretion of protein in the urine. This results in decreased serum protein and subsequent edema formation and low tissue hydrostatic pressure.
48
Which of the following actions will assist the nurse in evaluating the effectiveness of treatment for the patient with nephrotic syndrome?
a.
Monitoring the blood pressure every 4 hours
b.
Measuring the abdominal girth daily
c.
Measuring daily dietary protein intake
d.
Checking the urine of each voiding for protein
B
It is important to assess the edema by weighing the patient daily, accurately recording intake and output, and measuring abdominal girth or extremity size. Comparing this information daily provides the nurse with a tool for assessing the effectiveness of treatment.
49
The nurse notes that the results of an intravenous pyelogram indicate a left hydroureter and hydronephrosis in a female patient who was hospitalized with a markedly distended bladder. A catheterization for residual urine obtained 1650 mL. What does the nurse understand about these findings that are characteristic of a urinary tract obstruction?
a.
They are located at the bladder neck.
b.
They are caused by ureteral calculi.
c.
They are situated at the ureteropelvic junction.
d.
They are caused by a ureteral stricture.
A
When obstruction occurs at the level of the bladder neck or prostate, significant bladder changes can occur and are characteristic of a urinary tract obstruction.
50
A patient with a history of renal calculi is hospitalized with gross hematuria and severe colicky left flank pain that radiates to his left testicle. In planning care for the patient, the nurse gives the highest priority to which of the following nursing diagnoses?
a.
Acute pain related to irritation of stone
b.
Deficient fluid volume related to inadequate intake
c.
Risk for infection related to urinary system damage
d.
Altered health maintenance related to lack of knowledge about prevention of stones
A
Although all the diagnoses are appropriate, the initial nursing actions should focus on relief of the acute pain.
51
The nurse instructs a patient seen in the outpatient clinic with symptoms of renal calculi to strain all urine for which of the following primary purposes?
a.
To validate the diagnosis of kidney stones
b.
To obtain a stone for analysis of composition
c.
To determine when a stone has passed from the system
d.
To determine the extent of damage to the urinary system
B
Patients should strain their urine to obtain a stone. The patient saves the stone for analysis of the stone composition, which will help in determining treatment.
52
A patient with a confirmed renal calculus in the proximal left ureter undergoes extracorporeal shock wave lithotripsy, which successfully shatters the stone. After the lithotripsy, the nurse encourages fluids to 3000 mL/day and knows that the interventions for the patient have been effective based on which of the following findings?
a.
Free flow of urine is present.
b.
Adequate fluid balance is maintained.
c.
The patient verbalizes a decrease in pain.
d.
There is no indication of UTI.
A
Because lithotripsy breaks the stone into fine sand, which could cause obstruction, it is important to monitor the urinary output to ensure it is flowing freely.
53
The composition of a patient’s renal calculi is identified as uric acid. To prevent recurrence of stones, what should the nurse teach the patient to avoid?
a.
Milk and dairy products
b.
Legumes and dried fruits
c.
Spinach, chocolate, and tomatoes
d.
Organ meats and fish with fine bones
D
Organ meats and fish such as sardines increase purine levels and uric acid.
54
To prevent the recurrence of renal calculi, what should the nurse teach the patient to do?
a.
Avoid all sources of dietary calcium.
b.
Drink fluids such as cranberry juice and colas, which will acidify the urine.
c.
Maintain fluid intake at 3000 mL a day, especially when physically active.
d.
Empty the bladder every 2 to 4 hours to prevent urinary stasis and precipitation of urates.
C
A fluid intake of 3000 mL daily is recommended to help flush out minerals before stones can form.
55
In planning teaching for a patient with nephrosclerosis, what should the nurse include instructions about?
a.
Monitoring of daily intake and output amounts
b.
Maintenance of fluid restriction at 1000 mL/day
c.
Techniques of monitoring and recording blood pressure
d.
Prevention and detection of bleeding from anticoagulation therapy
C
Hypertension is the major symptom of nephrosclerosis; therefore, the patient should be able to monitor and record his or her blood pressure.
56
The nurse advises genetic counselling for the children of which of the following patients?
a.
A patient with interstitial cystitis
b.
A patient with horseshoe kidney
c.
A patient with polycystic kidney disease
d.
A patient with Goodpasture syndrome
C
The adult form of polycystic kidney disease is an autosomal dominant disorder; therefore, genetic counselling is warranted.
57
When assessing a patient who complains of a feeling of incomplete bladder emptying and a split, spraying urine stream, what history should the nurse ask about more specifically?
a.
Renal calculi
b.
Kidney trauma
c.
Bladder infection
d.
Gonococcal urethritis
D
The patient’s clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis.
58
The physician suspects transitional-cell bladder cancer in a 69-year-old patient who has gross hematuria and history of a 9-kg weight loss during the last 3 months, and schedules diagnostic testing. When obtaining a nursing history from the patient, the nurse identifies a significant risk factor for bladder cancer when the patient reports which of the following histories?
a.
Chronic cystitis
b.
Cigarette smoking
c.
High caffeine intake
d.
Use of artificial sweeteners
B
Cigarette smoking is a risk factor for bladder cancer.
59
To promote muscle relaxation and induce voiding after the patient has undergone an open loop resection and fulguration of the bladder, what is an appropriate intervention for the nurse to use?
a.
Sitz baths four times per day
b.
Encouraging fluids to 3000 mL/day
c.
Isometric exercises of the perineal muscles every 2 hours
d.
Application of warm compresses to the suprapubic area four times per day
A
Sitz baths will relax the perineal muscles and promote voiding.
60
A 78-year-old woman is admitted to the hospital with dehydration and electrolyte imbalance. She is confused and incontinent of urine on admission. In developing a plan of care for the patient, what is an appropriate nursing intervention for the patient’s incontinence?
a.
Insert an in-dwelling catheter.
b.
Apply absorbent incontinence pads.
c.
Restrict fluids after the evening meal.
d.
Assist the patient to the bathroom every 2 hours.
D
In older or confused patients, incontinence may be avoided by using scheduled toileting times.
61
After her bath, a 62-year-old woman asks the nurse for a perineal pad, saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which of the following interventions is most appropriate to include in a teaching plan to assist the patient with this problem?
a.
Performance of Kegel exercises
b.
Performance of Credé manoeuvre
c.
Use of bladder neck support devices
d.
Establishment of a pattern of urinating every 3 hours
A
Exercises to strengthen the pelvic floor muscles, such as Kegel exercises, will help reduce stress incontinence.
62
Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes. Which nursing action is most appropriate?
a.
Use an ultrasound scanner to check for residual urine after voiding.
b.
Have the patient take small amounts of fluid frequently throughout the day.
c.
Reassure the patient that this is normal after rectal surgery because of the anaesthesia.
d.
Monitor the patient’s intake and output over the next few hours.
A
An ultrasound scanner can be used to check for residual urine after the patient voids because the patient’s history and clinical manifestations are consistent with overflow.
63
What is the most common type of urinary tract calculi?
a.
Uric acid
b.
Cystine
c.
Calcium oxalate
d.
Struvite
C
Calcium oxalate is the most common urinary stone with an incidence of 30% to 40%.
64
A patient with a neurogenic bladder is to be taught intermittent catheterization for bladder emptying. What should the nurse teach the patient to do?
a.
Use a clean procedure with a new catheter each day.
b.
Use a new, sterile catheter and sterile gloves and procedure for each catheterization.
c.
Request prophylactic antibiotics if clean, rather than sterile, technique is going to be used.
d.
Wash and rinse the catheter and the hands with soap and water before and after each catheterization.
D
Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days.
65
To prevent the incidence of UTIs in a catheterized patient, which of the following actions should the nurse implement?
a.
Irrigate the catheter with an antiseptic solution.
b.
Apply an antiseptic solution to the perineum daily.
c.
Perform perineal cleansing with mild soap and water twice daily and as needed.
d.
Apply an antibiotic ointment around the catheter at the urinary meatus at least twice a day.
C
Perineal care (two times per day and when necessary) should include cleaning of the meatus–catheter junction with soap and water.
66
A patient undergoes a nephrectomy for massive trauma to the kidney resulting from a fall from a scaffold. Immediately postoperatively, which of the following assessment data is most important to communicate to the surgeon?
a.
Blood pressure is 102/48 mm Hg.
b.
Urinary output is 20 mL/hour for 2 hours.
c.
Crackles are heard at both lung bases.
d.
Incisional pain level is 8 on a scale of 10.
B
Because the urinary output should be at least 0.5 mL/kg/hour, a 40-mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site.
67
A patient undergoing a left ureterolithotomy returns to the surgical unit with a left ureteral catheter and a urethral catheter in place. To care for the catheters, what should the nurse do?
a.
Irrigate the ureteral catheter with 5 mL normal saline hourly.
b.
Clamp the ureteral catheter when drainage is less than 10 mL/hour.
c.
Keep the patient on bed rest until the catheter is removed.
d.
Alternately clamp and unclamp the ureteral catheter every other hour to determine total urinary output.
C
To avoid displacing the ureteral catheter, the patient is usually on bed rest until the catheter is removed
68
Which of the following is considered a storage symptom of a lower UTI?
a.
Dysuria
b.
Hesitancy
c.
Intermittency
d.
Urgency
D
Urgency is a storage symptom of an infection of the lower urinary tract.
69
When teaching a patient about adequate fluid intake, what does the nurse tell the patient regarding an appropriate amount of daily intake per kilogram of body weight?
a.
25 mL
b.
33 mL
c.
42 mL
d.
50 mL
B
To maintain adequate hydration the patient should drink at least 33 mL per kg of body weight.
70
The nurse anticipates that the patient with Goodpasture syndrome will be prescribed which one of the following medications?
a.
A diuretic
b.
An antihypertensive
c.
A corticosteroid
d.
Vitamin K injections
C
The patient with Goodpasture syndrome will be prescribed corticosteroids, immunosuppressive drugs, plasmapheresis, and dialysis.
71
When evaluating the laboratory results for a patient with increased secretion of the anterior pituitary hormones, the nurse would expect to find
a.
decreased serum thyroxine levels.
b.
elevated serum aldosterone levels.
c.
an increase in urinary free cortisol.
d.
low urinary excretion of catecholamines.
C
Increased secretion of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland will lead to an increase in serum and urinary cortisol levels. An increase, rather than a decrease, in thyroxine level would be expected with increased secretion of thyroid stimulating hormone (TSH) by the anterior pituitary. Aldosterone and catecholamine levels are not controlled by the anterior pituitary.
72
When the nurse is obtaining the health history, which statement by a patient indicates further assessment of thyroid function may be necessary?
a.
“I notice my breasts are tender lately.”
b.
“I am so thirsty that I drink all day long.”
c.
“I get up several times at night to urinate.”
d.
“I feel a lump in my throat when I swallow.”
D
Difficulty in swallowing can occur with a goiter. Nocturia is associated with diseases such as diabetes mellitus, diabetes insipidus, or chronic kidney disease. Breast tenderness would occur with excessive gonadal hormone levels. Thirst is a sign of disease such as diabetes.
73
A patient is admitted with a serum sodium level of 118 mEq/L. The nurse will anticipate the need for which diagnostic test?
a.
Urinary 17-ketosteroids
b.
Antidiuretic hormone level
c.
Growth hormone stimulation test
d.
Adrenocorticotropic hormone level
B
Elevated levels of antidiuretic hormone will cause water retention and decrease serum sodium levels. The other tests would not be helpful in determining possible causes of the patient’s hyponatremia.
74
The nurse is interviewing a patient who has a possible thyroid disorder. Which question will provide the most useful information?
a.
“What methods do you use to help cope with stress?”
b.
“Have you experienced any blurring or double vision?”
c.
“Do you have to get up at night to empty your bladder?”
d.
“Have you had any recent unplanned weight gain or loss?”
D
Because thyroid function affects metabolic rate, changes in weight may indicate hyper- or hypofunction of the thyroid gland. Nocturia, visual difficulty, and changes in stress level are associated with other endocrine disorders.
75
When a patient in the outpatient clinic has an order for blood cortisol testing, which instruction will the nurse provide for the patient?
a.
“Avoid adding any salt to your foods for 24 hours before the test.”
b.
“You will need to lie down for 30 minutes before the blood is drawn.”
c.
“Come to the laboratory to have the blood drawn early in the morning.”
d.
“Do not have anything to eat or drink before the blood test is obtained.”
C
Cortisol levels are usually drawn in the morning, when levels are highest. The other instructions would be given to patients who were having other endocrine testing.
76
A patient has a total serum calcium level of 13.3 mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for
a.
calcitonin levels.
b.
catecholamine levels.
c.
thyroid hormone levels.
d.
parathyroid hormone levels.
D
Parathyroid hormone is the major controller for blood calcium levels. Although calcitonin secretion is a countermechanism to parathyroid hormone, it does not play a major role in calcium balance. Catecholamine and thyroid hormone levels do not affect serum calcium level.
77
During a physical examination, the nurse finds that a patient’s thyroid gland cannot be palpated. The most appropriate action by the nurse is to
a.
palpate the patient’s neck more deeply.
b.
document that the thyroid was nonpalpable.
c.
notify the health care provider immediately.
d.
teach the patient about thyroid hormone testing.
B
The thyroid is frequently nonpalpable. The nurse should simply document the finding. There is no need to notify the health care provider immediately about a normal finding. There is no indication for TSH testing unless there is evidence of thyroid dysfunction. Deep palpation of the neck is not appropriate
78
When a patient has clinical manifestations of hypothyroidism, which laboratory value should the nurse review to determine whether the hypothyroidism is caused by a problem with the anterior pituitary gland or with the thyroid gland?
a.
Thyroxine (T4) level
b.
Triiodothyronine (T3) level
c.
Thyroid-stimulating hormone (TSH) level
d.
Thyrotropin-releasing hormone (TRH) level
C
A low TSH level indicates that the patient’s hypothyroidism is caused by decreased anterior pituitary secretion of TSH. Low T3 and T4 levels are not diagnostic of the primary cause of the hypothyroidism. TRH levels indicate the function of the hypothalamus.
79
When working with a patient who has diabetes mellitus, the nurse reviews the results of testing for glycosylated hemoglobin (HbA1C) to evaluate for
a.
glucose levels 2 hours after a meal.
b.
circulating, nonfasting glucose levels.
c.
glucose control over the past 3 months.
d.
hypoglycemic episodes in the past 90 days.
C
Glycosylated hemoglobin testing measures glucose control over the last 3 months. Glucose testing after a meal or random testing may reveal impaired glucose tolerance and indicate prediabetes, but it is not done on patients who already have a diagnosis of diabetes. There is no test to evaluate for hypoglycemic episodes in the past.
80
When a patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, the nurse will monitor for
a.
decreased urinary output.
b.
evidence of fluid overload.
c.
increased serum sodium levels.
d.
elevated serum potassium levels.
D
Because aldosterone increases the excretion of potassium, a medication that blocks aldosterone will tend to cause hyperkalemia. Aldosterone also promotes the reabsorption of sodium and water in the renal tubules, so spironolactone will tend to cause increased urine output, a decreased or normal serum sodium level, and signs of dehydration.
81
Which information about a patient with newly diagnosed diabetes mellitus will be most useful to the nurse in developing strategies for successful adaptation to this disease?
a.
Ideal weight
b.
Value system
c.
Activity level
d.
Visual changes
B
When dealing with a patient with a chronic condition such as diabetes, identification of the patient’s values and beliefs can assist the health care team in choosing strategies for successful lifestyle change. The other information also will be useful, but is not as important in developing an individualized plan for the necessary lifestyle changes.
82
A patient is scheduled for a growth hormone stimulation test. In preparation for the test, the nurse will obtain a
a.
basin of ice.
b.
cardiac monitor.
c.
vial of glargine insulin.
d.
vial of 50% dextrose solution.
D
Hypoglycemia is induced during the growth hormone stimulation test, and the nurse should be ready to administer 50% dextrose immediately. Regular insulin is used to induce hypoglycemia (glargine is never given intravenously). The patient does not require cardiac monitoring during the test. Although blood samples for some tests must be kept on ice, this is not true for the growth hormone stimulation test.
83
The nurse will plan patient care that will decrease the patient’s physical and emotional stress when the patient is undergoing
a.
a water deprivation test.
b.
testing for serum T3 and T4 levels.
c.
a 24-hour urine test for free cortisol.
d.
a radioactive iodine (I-131) uptake test.
C
Physical and emotional stress can affect the results for the free cortisol test. The other tests are not impacted by stress.
84
A patient is scheduled for a 24-hour urine collection for 17-ketosteroids. The nurse will need to
a.
keep the specimen on ice.
b.
insert a retention catheter.
c.
have the patient void and save that specimen to start the collection.
d.
encourage the patient to drink 2 to 3 L of fluid during the 24 hours.
A
The specimen must be kept on ice or refrigerated until the collection is finished. Voided or catheterized specimens are acceptable for the test. The initial voided specimen is discarded. There is no fluid intake requirement for the 24-hour collection.
85
When reviewing the laboratory results for a patient’s total calcium level, which information will the nurse need to consider?
a.
The blood glucose is elevated.
b.
The phosphate level is normal.
c.
The serum albumin level is low.
d.
The magnesium level is normal.
C
Part of the total calcium is bound to albumin so hypoalbuminemia can lead to misinterpretation of calcium levels. The other laboratory values will not affect total calcium interpretation.
86
When the nurse is caring for a patient who was admitted with tetany, which laboratory value should be monitored?
a.
Total protein
b.
Blood glucose
c.
Ionized calcium
d.
Serum phosphate
C
Tetany is associated with hypocalcemia. The other values would not be useful for this patient.
87
Which information about a patient who is scheduled for an oral glucose tolerance test should be reported to the health care provider before starting the test?
a.
The patient reports having occasional orthostatic dizziness.
b.
The patient has had a 10-pound weight gain in the last month.
c.
The patient drank several glasses of water an hour previously.
d.
The patient takes oral corticosteroids for rheumatoid arthritis.
D
Corticosteroids can affect blood glucose results. The other information will be provided to the provider, but will not affect the test results.
88
After the nurse manager at the endocrine clinic has completed the orientation of a new RN, which action by the new RN who is caring for a patient with a goiter and possible hyperthyroidism indicates the charge nurse needs to do more teaching?
a.
The RN palpates the neck to check thyroid size.
b.
The RN checks the blood pressure on both arms.
c.
The RN orders nonmedicated eye drops to lubricate the patient’s eyes.
d.
The RN lowers the thermostat to decrease the temperature in the room.
A
Palpation can cause the release of thyroid hormones in a patient with an enlarged thyroid and should be avoided. The other actions by the new RN are appropriate when caring for a patient with an enlarged thyroid.
89
When caring for a patient having a water deprivation test, which finding is most important for the nurse to communicate to the health care provider?
a.
The patient complains of intense thirst.
b.
The patient has a 5-lb (2.3 kg) weight loss.
c.
The patient feels dizzy when sitting up on the edge of the bed.
d.
The patient’s urine osmolality does not change after antidiuretic hormone (ADH) is given.
B
A drop in the weight of more than 2 kg indicates severe dehydration, and the test should be discontinued. The other assessment data are not unusual with this test.
90
A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is most important for the nurse to communicate to the health care provider before the test?
a.
Bilateral poor peripheral vision
b.
Allergies to iodine and shellfish
c.
Recent weight loss of 20 pounds
d.
Complaints of ongoing headaches
B
Since the usual contrast media is iodine-based, the health care provider will need to know about the allergy before the CT scan. The other findings are common with any mass in the brain such as a pituitary adenoma.
91
A patient is hospitalized with a severe myocardial infarction (MI) accompanied by cardiogenic shock. A week following his MI, his urinary output falls to 380 mL/day, and his blood urea nitrogen (BUN) and serum creatinine levels indicate that he is in the maintenance phase of acute renal failure (ARF). Which clinical finding would the nurse expect during this phase?
a.
Hypotension
b.
Hypernatremia
c.
Low urine specific gravity
d.
Epithelial cell casts in the urine
C
The maintenance phase may last from days to weeks. During this phase, patients may be anuric, oliguric, or nonoliguric. In this case, a diluted urine (low specific gravity) is being made, but uremic toxins are not being removed.
92
A patient with ARF has an arterial blood pH of 7.30. Which of the following will the nurse assess for?
a.
Tachycardia
b.
Rapid respirations
c.
Poor skin turgor
d.
Vasodilation
B
Patients with metabolic acidosis caused by ARF may have Kussmaul’s respirations as the lungs try to regulate carbon dioxide.
93
A patient with congestive heart failure and pulmonary edema develops early symptoms of ARF. The nurse plans care for the patient based on the knowledge that collaborative care of the renal failure will be directed toward which of the following goals?
a.
Promoting diuresis
b.
Replacing fluid volume
c.
Maintaining cardiac output
d.
Diluting nephrotoxic substances
C
The primary goal of treatment for ARF is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient’s heart failure is causing ARF, the care will be directed toward treatment of the heart failure.
94
The nurse would expect that the most pronounced elevations in serum potassium and BUN would occur in patients who have ARF resulting from which of the following conditions?
a.
Cardiogenic shock
b.
Nephrotoxic drugs
c.
Severe crushing injuries
d.
Renal vascular obstruction
C
The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately.
95
A patient admitted with sepsis has had several episodes of severe hypotension. Laboratory results indicate a BUN of 10.7 mmol/L (30 mg/dL), serum creatinine of 177 micromol/L (2.0 mg/dL), urine sodium of 70 mmol/L, urine specific gravity of 1.01, and cellular casts and debris in the urine. The nurse knows these findings are consistent with which condition?
a.
Uremia
b.
Prerenal failure
c.
Post renal failure
d.
Acute tubular necrosis
D
The specific gravity and presence of casts and debris in the urinalysis suggest intrarenal failure and acute tubular necrosis.
96
A patient in the oliguric phase of ARF has a 24-hour fluid output of 150 mL emesis and 250 mL urine. The nurse plans for which amount of fluid replacements for the following day?
a.
400 mL
b.
800 mL
c.
1000 mL
d.
1400 mL
C
Usually, fluid replacement should be based on the patient’s measured output plus 600 mL/day for insensible losses.
97
When administering treatment for a patient who has hyperkalemia, the nurse will anticipate administration of which of the following to cause the potassium to move into the cells?
a.
Calcium gluconate
b.
Sodium bicarbonate
c.
Furosemide
d.
Insulin
D
Regular intravenous (IV) insulin administration causes potassium to move into cells.
98
A patient in ARF has a gradual increase in urinary output to 3400 mL a day with a BUN of 33 mmol/L (92 mg/dL) and a serum creatinine of 371 micromol/L (4.2 mg/dL). The nurse should plan to do which of the following?
a.
Use a urine dipstick to monitor for proteinuria.
b.
Auscultate the lungs to assess for pulmonary edema.
c.
Take the blood pressure to check for hypotension.
d.
Draw blood to monitor for hyperkalemia.
C
During the diuretic phase of ARF, fluid and electrolyte losses may cause hypovolemia, hypotension, hyponatremia, and hypokalemia; therefore, the nurse should monitor the blood pressure to assess for hypotension.
99
To prevent the most common cause of death of patients in acute kidney injury (AKI), what should the nurse do?
a.
Restrict fluids to 500 to 600 mL/day.
b.
Monitor cardiac function to detect early dysrhythmia.
c.
Observe and accurately record all fluid intake and output.
d.
Maintain meticulous medical and surgical asepsis in the delivery of all care.
D
Because infection is the leading cause of death overall in AKI, meticulous aseptic technique is critical. The patient should be protected from other individuals with infectious diseases.
100
After noting increasing QRS intervals in a patient with ARF, which action should the nurse take first?
a.
Notify the patient’s physician.
b.
Check the chart for the most recent blood potassium level.
c.
Look at the patient’s current BUN and creatinine levels.
d.
Document the QRS interval.
B
The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient’s physician.
101
Chronic uremia affects multiple body systems. Which of the following is a clinical manifestation of the integumentary system that is often seen in patients with chronic uremia?
a.
Petechiae
b.
Dermatitis
c.
Ecchymosis
d.
Spider nevi
C
There are three common integumentary clinical manifestations of chronic uremia: pruritus, ecchymosis, and dry, scaly skin.
102
A patient is diagnosed with stage 3 chronic kidney disease (CKD). The patient is treated with conservative management, including erythropoietin injections. After teaching the patient about management of CKD, the nurse determines that teaching has been effective when the patient states which of the following?
a.
“I will measure my urinary output each day to help calculate the amount I can drink.”
b.
“I need to take the erythropoietin to boost my immune system and help prevent infection.”
c.
“I need to try to get more protein from dairy products.”
d.
“I will try to increase my intake of fruits and vegetables.”
A
The patient with CKD who is not receiving dialysis is generally taught to restrict fluids. The patient would need to measure urinary output and then add 600 mL for insensible losses to calculate an appropriate oral intake.
103
A patient with CKD has a nursing diagnosis of disturbed sensory perception related to central nervous system changes induced by uremic toxins. What is an appropriate nursing intervention for this problem?
a.
Convey a caring attitude and foster the nurse–patient relationship.
b.
Avoid fruits and vegetables as sources of high potassium in the diet.
c.
Ensure restricted protein intake to prevent nitrogenous product accumulation.
d.
Provide an opportunity for the patient to discuss concerns about his condition.
C
Uremia is caused by the products of protein breakdown, and protein restriction is used to decrease uremia.
104
As the nurse and the dietitian review a diet plan with a patient with diabetes with newly diagnosed renal insufficiency, the patient becomes very angry, shouting that with her diabetes and now the kidney failure, there is just nothing she can eat. She says she might as well eat what she wants because these diseases will kill her anyway. Based on the patient’s response, the nurse identifies which of the following nursing diagnoses?
a.
Ineffective coping related to emotional lability
b.
Risk for noncompliance related to feelings of anger
c.
Anticipatory grieving related to actual and perceived losses
d.
Risk for ineffective health maintenance related to complexity of therapeutic regimen
C
The patient’s statements that there is nothing that is good to eat and that death is unavoidable indicate grieving about the losses being experienced as a result of the diabetes and CKD.
105
Before administering sodium polystyrene sulphonate (Kayexalate) to a patient with hyperkalemia, what should the nurse assess for?
a.
BUN and creatinine
b.
Blood glucose level
c.
Patient’s bowel sounds
d.
Level of consciousness
C
Sodium polystyrene sulphonate should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur.
106
The nurse has instructed a patient who is receiving hemodialysis about dietary management. Which diet choice by the patient indicates that the teaching has been successful?
a.
Scrambled eggs, English muffin, and apple juice
b.
Cheese sandwich, tomato soup, and cranberry juice
c.
Split-pea soup, whole-wheat toast, and nonfat milk
d.
Oatmeal with cream, half a banana, and herbal tea
A
Scrambled eggs would provide high-quality protein, and apple juice is low in potassium.
107
Before administration of calcitriol (Rocaltrol) to a patient with CKD, the nurse should check the laboratory value for which of the following?
a.
Serum phosphate
b.
Total cholesterol
c.
Creatinine
d.
Potassium
A
If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcitriol should not be given until the phosphate level is lowered.
108
A patient is being initiated on peritoneal dialysis. What should the nurse teach the patient in relation to fluid allowance?
a.
Limit intake to 1000 mL per day.
b.
Adjust intake to equal output plus 300 mL per day.
c.
Adjust intake to equal output plus 600 mL per day.
d.
Often there is no fluid restriction.
D
With peritoneal dialysis, there is often no restriction on fluid allowance.
109
A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous fistula and a graft. What should the nurse explain is one advantage of the fistula over the graft?
a.
It increases patient mobility.
b.
It is much less likely to clot.
c.
It can accommodate larger needles.
d.
It can be used sooner after the surgery.
B
Arteriovenous fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis.
110
In preparation for hemodialysis, a patient has an arteriovenous native fistula created in the left forearm. To assess and maintain the patency of the fistula postoperatively, what should the nurse do?
a.
Auscultate the fistula site for a bruit.
b.
Assess the rate and quality of the radial pulse.
c.
Assess the blood pressure in the affected arm.
d.
Irrigate the fistula site daily with low-dose heparin.
A
The presence of a thrill and bruit indicates adequate blood flow through the fistula.
111
When teaching a patient about potassium-containing foods, which of the following foods would the nurse recommend as having an extremely high amount of potassium (\>10 mmol per serving)?
a.
Apple juice
b.
Tomatoes
c.
Carrots
d.
Squash
D
Although all of the foods listed contain potassium, squash has the highest amount, with greater than 10 mmol of potassium per serving.
112
A patient with CKD is started on hemodialysis, and after the first treatment, the patient complains of nausea and a headache. The nurse notes mild jerking and twitching of the patient’s extremities. The nurse will anticipate the need to do which of the following?
a.
Increase the time for the next dialysis to remove wastes more completely.
b.
Switch to continuous renal replacement therapy to improve dialysis efficiency.
c.
Administer medications to control these symptoms before the next dialysis.
d.
Slow the rate for the next dialysis to decrease the speed of solute removal.
D
The patient has symptoms of disequilibrium syndrome, which can be prevented by slowing the rate of dialysis so that fewer solutes are removed during the dialysis.
113
A 54-year-old patient with diabetes and CKD is considering using continuous ambulatory peritoneal dialysis (CAPD) as her renal failure becomes worse. In discussing this treatment option with the patient, what should the nurse tell the patient?
a.
Patients with diabetes respond better to CAPD than to hemodialysis.
b.
Home CAPD requires more extensive equipment than does home hemodialysis.
c.
CAPD is contraindicated for patients who may eventually want a kidney transplant.
d.
Patients receiving CAPD have more dietary restrictions than are required with hemodialysis.
A
Patients with diabetes have better control of blood pressure, less hemodynamic instability, and fewer problems with retinal hemorrhages when using peritoneal dialysis than when using hemodialysis.
114
A patient who has been on CAPD for 8 months is hospitalized with a detached retina. She is receiving CAPD with four exchanges a day while she is hospitalized. During the dialysate inflow, the patient tells the nurse that she is having abdominal pain and pain in her right shoulder. What should the nurse do?
a.
Massage the patient’s abdomen.
b.
Decrease the rate of dialysate infusion.
c.
Stop the infusion and notify the physician.
d.
Ask the patient whether she can empty her bowel.
B
Abdominal pain and referred shoulder pain can be caused by a rapid infusion of dialysate; the nurse should slow the rate of the infusion.
115
The nurse is assessing a patient who is receiving peritoneal dialysis with 2-L inflows. Which information should be reported immediately to the physician?
a.
The patient is complaining of feeling bloated after the inflow.
b.
The patient’s peritoneal effluent appears cloudy.
c.
The patient has abdominal pain during the inflow phase.
d.
The patient has an outflow volume of 1600 mL.
B
Cloudy-appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started.
116
In the immediate postoperative period, when caring for a patient who is a recipient of a kidney transplant, the nurse would expect that fluid therapy would involve administration of which of the following IV fluid infusion principles?
a.
Maintain at a minimum rate of 100 mL/hour to perfuse the kidney.
b.
Maintain at a rate to keep blood pressure within a normal range.
c.
Determine rate maintenance hourly, based on every millilitre of urinary output.
d.
Administer at a rate to keep urine clear, without evidence of blood clots.
C
Fluid volume is replaced based on urinary output after transplant because the urinary output can be as high as a litre an hour.
117
A patient is receiving immunosuppressive drugs following a living related-donor kidney transplant. To monitor for corticosteroid-related complications, the nurse teaches the patient to report which of the following?
a.
Pain at the donor kidney site
b.
Dizziness with position change
c.
Changes in the character of the urine
d.
Pain in the hips, knees, and other joints
D
Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period.
118
Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the physician?
a.
The BUN and creatinine levels are elevated.
b.
The urinary output is 900 to 1100 mL/hour.
c.
The patient’s central venous pressure (CVP) is decreased.
d.
The patient has level 8 (on a 10-point scale) incision pain when coughing.
C
The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis.
119
Which data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse?
a.
The blood glucose is 8 mmol/L (144 mg/dL).
b.
The patient has a round, moonlike face.
c.
The patient has a nontender lump in the axilla.
d.
The patient’s blood pressure is 150/92 mm Hg.
C
A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy.
120
A patient with CKD brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required?
a.
Milk of magnesia 30 mL administered orally
b.
Oral acetaminophen (Tylenol) 650 mg
c.
Multivitamin with iron
d.
Calcium phosphate (PhosLo)
A
Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium.
121
A patient with hypertension and stage 2 CKD is receiving captopril (Capoten). Before administration of the medication, the nurse will check the level of which of the following?
a.
Creatinine
b.
Glucose
c.
Phosphate
d.
Potassium
D
Angiotensin-converting enzyme inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention; therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia.
122
A new order for IV gentamicin (Garamycin) 60 mg twice daily is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patient for which of the following?
a.
Blood glucose
b.
Serum potassium
c.
BUN and creatinine
d.
Urine osmolality
C
When a patient at risk for CKD receives a nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels.
123
A patient receiving peritoneal dialysis using 2 L of dialysate per exchange has an outflow of 1200 mL. Which of the following actions should the nurse take first?
a.
Infuse 1200 mL of dialysate during the inflow.
b.
Assist the patient in changing position.
c.
Administer a laxative to the patient.
d.
Notify the physician about the outflow problem.
B
Outflow problems may occur because the peritoneal catheter is collapsed by a portion of the intestine, and repositioning the patient will move the catheter and allow outflow to occur.
124
Which of the following is the preferred hemodialysis vascular access site?
a.
Nontunnelled central venous catheter
b.
Arteriovenous fistula
c.
Tunnelled central venous catheter
d.
Arteriovenous graft
B
Although all four vascular access sites can be used for hemodialysis, the preferred one is the arteriovenous fistula.
125
A patient complains of leg cramps during hemodialysis. What should the nurse do?
a.
Give acetaminophen.
b.
Infuse a bolus of normal saline.
c.
Massage the patient’s legs.
d.
Reposition the patient.
B
Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline
126
A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what “type 2” means in relation to diabetes. Which statement by the nurse about type 2 diabetes is correct?
a.
Insulin is not used to control blood glucose in patients with type 2 diabetes.
b.
Complications of type 2 diabetes are less serious than those of type 1 diabetes.
c.
Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.
d.
Changes in diet and exercise may be sufficient to control blood glucose levels in type 2 diabetes.
D
For some patients, changes in lifestyle are sufficient for blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.
127
A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about
a.
self-monitoring of blood glucose.
b.
use of low doses of regular insulin.
c.
lifestyle changes to lower blood glucose.
d.
effects of oral hypoglycemic medications.
C
The patient’s impaired fasting glucose indicates prediabetes and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or the oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.
128
Which action by a type 1 diabetic patient indicates that the nurse should implement teaching about exercise and glucose control?
a.
The patient always carries hard candies when engaging in exercise.
b.
The patient goes for a vigorous walk when the glucose is 200 mg/dL.
c.
The patient has a peanut butter sandwich before going for a bicycle ride.
d.
The patient increases daily exercise when ketones are present in the urine.
D
When the patient is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic patients should be taught to avoid exercise when ketosis is present. The other statements are correct
129
When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question is most appropriate for the nurse to ask?
a.
“Have you lost any weight lately?”
b.
“How long have you felt anorexic?”
c.
“Is your urine unusually dark colored?”
d.
“Do you crave fluids containing sugar?”
A
Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.
130
To evaluate the effectiveness of treatment for a patient with type 2 diabetes who is scheduled for a follow-up visit in the clinic, which test will the nurse plan to schedule for the patient?
a.
Urine dipstick for glucose
b.
Oral glucose tolerance test
c.
Fasting blood glucose level
d.
Glycosylated hemoglobin level
D
The glycosylated hemoglobin (Hb A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed.
131
A patient who has just been diagnosed with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which patient goal is most important for this patient?
a.
The patient will have a glycosylated hemoglobin level of less than 7%.
b.
The patient will have a diet and exercise plan that results in weight loss.
c.
The patient will choose a diet that distributes calories throughout the day.
d.
The patient will state the reasons for eliminating simple sugars in the diet.
A
The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes also are appropriate but are not as high in priority.
132
A patient who has type 1 diabetes plans to take a swimming class daily at 1:00 PM. The clinic nurse will plan to teach the patient to
a.
check glucose level before, during, and after swimming.
b.
delay eating the noon meal until after the swimming class.
c.
increase the morning dose of neutral protamine Hagedorn (NPH) insulin.
d.
time the morning insulin injection so that the peak occurs while swimming.
A
The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.
133
An 18-year-old with newly diagnosed type 1 diabetes has received diet instruction. The nurse determines a need for additional instruction when the patient says,
a.
“I may have an occasional alcoholic drink if I include it in my meal plan.”
b.
“I will need a bedtime snack because I take an evening dose of NPH insulin.”
c.
“I may eat whatever I want, as long as I use enough insulin to cover the calories.”
d.
“I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia.”
C
Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.
134
Which action is most important for the nurse to take in order to assist a diabetic patient to engage in moderate daily exercise?
a.
Remind the patient that exercise will improve self-esteem.
b.
Determine what type of exercise activities the patient enjoys.
c.
Give the patient a list of activities that are moderate in intensity.
d.
Teach the patient about the effects of exercise on glucose level.
B
Since consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program. The other actions also will be implemented, but are not the most important in improving compliance.
135
The nurse has been teaching the patient to administer a dose of 10 units of regular insulin and 28 units of NPH insulin. The statement by the patient that indicates a need for additional instruction is,
a.
“I need to rotate injection sites among my arms, legs, and abdomen each day.”
b.
“I will buy the 0.5 mL syringes because the line markings will be easier to see.”
c.
“I should draw up the regular insulin first after injecting air into the NPH bottle.”
d.
“I do not need to aspirate the plunger to check for blood before injecting insulin.”
A
Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed.
136
After the nurse has finished teaching a patient about self-administration of the prescribed aspart (NovoLog) insulin, which patient action indicates good understanding of the teaching?
a.
The patient avoids injecting the insulin into the upper abdominal area.
b.
The patient cleans the skin with soap and water before insulin administration.
c.
The patient places the insulin back in the freezer after administering the prescribed insulin dose.
d.
The patient pushes the plunger down and immediately removes the syringe from the injection site.
B
Cleaning the skin with soap and water or with alcohol is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred areas for insulin injection.
137
A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia?
a.
9:00 AM
b.
11:30 AM
c.
4:00 PM
d.
8:00 PM
A
The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur.
138
Which patient action indicates a good understanding of the nurse’s teaching about the use of an insulin pump?
a.
The patient changes the site for the insertion site every week.
b.
The patient programs the pump to deliver an insulin bolus after eating.
c.
The patient takes the pump off at bedtime and starts it again each morning.
d.
The patient states that diet will be less flexible when using the insulin pump.
B
In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used. The pump will deliver a basal insulin rate 24 hours a day.
139
When teaching a diabetic patient who has just been started on intensive insulin therapy about mealtime coverage, which type of insulin will the nurse need to discuss?
a.
glargine (Lantus)
b.
lispro (Humalog)
c.
detemir (Levemir)
d.
NPH (Humulin N)
B
Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.
140
Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)?
a.
Glyburide decreases glucagon secretion from the pancreas.
b.
Glyburide stimulates insulin production and release from the pancreas.
c.
Glyburide should be taken even if the morning blood glucose level is low.
d.
Glyburide should not be used for 48 hours after receiving IV contrast media.
B
The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, because hypoglycemia can occur with this category of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide.
141
Which patient statement after the nurse has completed teaching a patient with type 2 diabetes about taking glipizide (Glucotrol) indicates a need for additional teaching?
a.
“Other medications besides the Glucotrol may affect my blood sugar.”
b.
“If I overeat at a meal, I will still take just the usual dose of medication.”
c.
“When I become ill, I may have to take insulin to control my blood sugar.”
d.
“My diabetes is not as likely to cause complications as if I needed to take insulin.”
D
The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.
142
A patient with type 2 diabetes that is well-controlled with metformin (Glucophage) develops an allergic rash to an antibiotic and the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may
a.
need a diet higher in calories while receiving prednisone.
b.
require administration of insulin while taking prednisone.
c.
develop acute hypoglycemia while taking the prednisone.
d.
have rashes caused by metformin-prednisone interactions.
B
Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone, but will not need a diet that is higher in calories.
143
A hospitalized diabetic patient who received 34 U of NPH insulin at 7:00 AM is away from the nursing unit, awaiting diagnostic testing when lunch trays are distributed. To prevent hypoglycemia, the best action by the nurse is to
a.
save the lunch tray to be provided upon the patient’s return to the unit.
b.
call the diagnostic testing area and ask that a 5% dextrose IV be started.
c.
ensure that the patient drinks a glass of milk or orange juice at noon in the diagnostic testing area.
d.
request that the patient be returned to the unit to eat lunch if testing will not be completed promptly.
D
Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.
144
A patient with type 1 diabetes has been using self-monitoring of blood glucose (SMBG) as part of diabetes management. During evaluation of the patient’s technique of SMBG, the nurse identifies a need for additional teaching when the patient
a.
washes the puncture site using soap and warm water.
b.
chooses a puncture site in the center of the finger pad.
c.
hangs the arm down for a minute before puncturing the site.
d.
says the result of 130 mg indicates good blood sugar control.
B
The patient is taught to choose a puncture site at the side of the finger pad. The other patient actions indicate that teaching has been effective.
145
Which action should the nurse take first when teaching a patient who is newly diagnosed with type 2 diabetes about home management of the disease?
a.
Ask the patient’s family to participate in the diabetes education program.
b.
Assess the patient’s perception of what it means to have diabetes mellitus.
c.
Demonstrate how to check glucose using capillary blood glucose monitoring.
d.
Discuss the need for the patient to actively participate in diabetes management.
B
Before planning education, the nurse should assess the patient’s interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient
146
A diagnosis of hyperglycemic hyperosmolar nonketotic coma (HHNC) is made for a patient with type 2 diabetes who is brought to the emergency department in an unresponsive state. The nurse will anticipate the need to
a.
give 50% dextrose as a bolus.
b.
insert a large-bore IV catheter.
c.
initiate oxygen by nasal cannula.
d.
administer glargine (Lantus) insulin.
B
HHNC is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient’s blood glucose and would be contraindicated.
147
A patient with type 1 diabetes who uses glargine (Lantus) and lispro (Humalog) insulin develops a sore throat, cough, and fever. When the patient calls the clinic to report the symptoms and a blood glucose level of 210 mg/dL, the nurse advises the patient to
a.
use only the lispro insulin until the symptoms of infection are resolved.
b.
monitor blood glucose every 4 hours and notify the clinic if it continues to rise.
c.
decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.
d.
limit intake of calorie-containing liquids until the glucose is less than 120 mg/dL.
B
Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobins are not used to test for short-term alterations in blood glucose.
148
The health care provider suspects the Somogyi effect in a patient whose 7:00 AM blood glucose is 220 mg/dL. Which action will the nurse plan to take?
a.
Check the patient’s blood glucose at 3:00 AM.
b.
Administer a larger dose of long-acting insulin.
c.
Educate about the need to increase the rapid-acting insulin dose.
d.
Remind the patient about the need to avoid snacking at bedtime.
A
If the Somogyi effect is causing the patient’s increased morning glucose level, the patient will experience hypoglycemia between 2 and 4 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night.
149
Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness?
a.
Assess the patient for symptoms of hyperglycemia.
b.
Give the patient a snack of crackers and peanut butter.
c.
Have the patient drink a glass of orange juice or nonfat milk.
d.
Administer a continuous infusion of 5% dextrose for 24 hours.
B
Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.
150
Which question by the nurse will help identify autonomic neuropathy in a diabetic patient?
a.
“Have you observed any recent skin changes?”
b.
“Do you notice any bloating feeling after eating?”
c.
“Do you need to increase your insulin dosage when you are stressed?”
d.
“Have you noticed any painful new ulcerations or sores on your feet?”
B
Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions also are appropriate to ask, but would not help in identifying autonomic neuropathy.
151
A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral arterial disease. Which information will the nurse include in patient teaching?
a.
Choose flat-soled leather shoes.
b.
Set heating pads on a low temperature.
c.
Buy callus remover for corns or calluses.
d.
Soak the feet in warm water for an hour every day.
A
The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems.
152
The nurse obtains the following information about a patient before administration of metformin (Glucophage). Which finding indicates a need to contact the health care provider before giving the metformin?
a.
The patient’s blood glucose level is 166 mg/dL.
b.
The patient’s blood urea nitrogen (BUN) level is 60 mg/dL.
c.
The patient is scheduled for a chest x-ray in an hour.
d.
The patient has gained 2 lb (0.9 kg) since yesterday.
B
The BUN indicates impending renal failure and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin.
153
Amitriptyline (Elavil) is prescribed for a diabetic patient who has burning foot pain at night. Which information should the nurse include when teaching the patient about the new medication?
a.
Amitriptyline will decrease the depression caused by your foot pain.
b.
Amitriptyline will correct some of the blood vessel changes that cause pain.
c.
Amitriptyline will improve sleep and make you less aware of nighttime pain.
d.
Amitriptyline will help prevent the transmission of pain impulses to the brain.
D
Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclics also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclics.
154
A patient with type 2 diabetes is admitted for an outpatient coronary arteriogram. Which information obtained by the nurse is most important to report to the health care provider before the procedure?
a.
The patient’s admission blood glucose is 128 mg/dL.
b.
The patient’s most recent Hb A1C was 6.5%.
c.
The patient took the prescribed metformin (Glucophage) today.
d.
The patient took the prescribed captopril (Capoten) this morning.
C
To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary arteriogram and should not be used for 48 hours after IV contrast media are administered. The other patient data also will be reported but do not indicate any need to reschedule the procedure.
155
After the home health nurse has taught a patient and family about how to use glargine and regular insulin safely, which action by the patient indicates that the teaching has been successful?
a.
The patient administers the glargine 30 to 45 minutes before eating each meal.
b.
The patient’s family fills the syringes weekly and stores them in the refrigerator.
c.
The patient draws up the regular insulin and then the glargine in the same syringe.
d.
The patient disposes of the open vials of glargine and regular insulin after 4 weeks.
D
Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, while glargine is given once daily.
156
The nurse teaches the diabetic patient who rides a bicycle to work every day to administer morning insulin into the
a.
arm.
b.
thigh.
c.
buttock.
d.
abdomen.
D
Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.
157
Which information about a patient who receives rosiglitazone (Avandia) is most important for the nurse to report immediately to the health care provider?
a.
The patient’s blood pressure is 154/92.
b.
The patient has a history of emphysema.
c.
The patient’s noon blood glucose is 86 mg/dL.
d.
The patient has chest pressure when ambulating.
D
Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication. There is no urgent need to discuss the other data with the health care provider
158
A pregnant patient who has no personal history of diabetes, but does have a parent who is diabetic is scheduled for the first prenatal visit. Which action will the nurse plan to take on this initial visit?
a.
Teach about appropriate use of regular insulin.
b.
Discuss the need for a fasting blood glucose level.
c.
Schedule an oral glucose tolerance test for the twenty fourth week of pregnancy.
d.
Provide education about increased risk for fetal problems with gestational diabetes.
B
Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose tolerance test also may be used to check for diabetes, but it would be done before the twenty fourth week. The other actions also may be needed (depending on whether the patient develops gestational diabetes), but they are not the first actions that the nurse should take.
159
A patient is admitted with diabetic ketoacidosis (DKA) and has a serum potassium level of 2.9 mEq/L. Which action prescribed by the health care provider should the nurse take first?
a.
Infuse regular insulin at 20 U/hr.
b.
Place the patient on a cardiac monitor.
c.
Administer IV potassium supplements.
d.
Obtain urine glucose and ketone levels.
B
Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Since potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring, since insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patient’s care.
160
A diabetic patient is admitted with ketoacidosis and the health care provider writes these orders. Which order should the nurse implement first?
a.
Administer regular IV insulin 30 U.
b.
Infuse 1 liter of normal saline per hour.
c.
Give sodium bicarbonate 50 mEq IV push.
d.
Start an infusion of regular insulin at 50 U/hr.
B
The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be accomplished after the infusion of normal saline is initiated.
161
When the nurse is assessing a patient who is recovering from an episode of diabetic ketoacidosis, the patient reports feeling anxious, nervous, and sweaty. Which action should the nurse take first?
a.
Administer 1 mg glucagon subcutaneously.
b.
Obtain a glucose reading using a finger stick.
c.
Have the patient drink 4 ounces of orange juice.
d.
Give the scheduled dose of lispro (Humalog) insulin.
B
The patient’s clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient’s glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the patient’s symptoms become worse or if the patient is unconscious. Administration of lispro would drop the patient’s glucose further.
162
Which information from the patient’s health history is most important for the nurse to communicate to the health care provider when a patient has an order for an oral glucose tolerance test?
a.
The patient uses oral contraceptives.
b.
The patient runs several days a week.
c.
The patient has a family history of diabetes.
d.
The patient had a viral illness 2 months ago.
A
Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. A viral illness 2 months previously may be associated with the onset of type 1 diabetes but will not falsely affect the OGTT. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT.
163
Which of these laboratory values, noted by the nurse when reviewing the chart of a hospitalized diabetic patient, indicates the need for rapid assessment of the patient?
a.
Hb A1C of 5.8%
b.
Noon blood glucose of 52 mg/dL
c.
Hb A1Cof 6.9%
d.
Fasting blood glucose of 130 mg/dL
B
The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient.
164
The nurse and LPN/LVN are caring for a type 2 diabetic patient who is admitted for gallbladder surgery. Which nursing action can the nurse delegate to the LPN/LVN?
a.
Communicate the blood glucose and insulin dose to the circulating nurse in surgery.
b.
Discuss the reason for the use of insulin therapy during the immediate postoperative period.
c.
Administer the prescribed lispro (Humalog) insulin before transferring the patient to surgery.
d.
Plan strategies to minimize the risk for hypo- or hyperglycemia during the postoperative hospitalization.
C
LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with other departments, planning, and patient teaching are skills that require RN education and scope of practice.
