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Exam 3 test bank
Terms in this set (43)
What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?
a. Assess for the presence of chest pain.
b. Inquire about urinary tract problems.
c. Inspect the skin for rashes or discoloration.
d. Ask the patient about any increase in libido.
Urinary tract problems with incontinence or retention are common symptoms of MS. Chest
pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.
A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. How should the nurse respond?
a. "MS symptoms will be worse after the pregnancy."
b. "Women with MS frequently have premature labor."
c. "Symptoms of MS are likely to improve during pregnancy."
d. "MS is associated with an increased risk for congenital defects."
Symptoms of MS may improve during pregnancy. There is no increased risk for congenital
defects in infants born of mothers with MS. Onset of labor is not affected by MS. MS
symptoms will not worsen after pregnancy.
A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information should the nurse include in patient teaching?
a. Recommendation to drink at least 4 L of fluid daily
b. Need to avoid driving or operating heavy machinery
c. How to draw up and administer injections of the medication?
d. Use of contraceptive methods other than oral contraceptives
Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for
birth control. There is no need to avoid driving or drink large fluid volumes when taking
Which information about a patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?
a. The patient reports pain with neck flexion.
b. The patient has increased serum creatinine.
c. The patient walks a mile each day for exercise.
d. The patient has the relapsing-remitting form of MS.
Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.
Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?
a. Encourage decreased evening intake of fluid.
b. Teach the patient how to use the Credé method.
c. Suggest the use of adult incontinence briefs for nighttime only.
d. Assist the patient to the commode every 2 hours during the day.
The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not
improve bladder emptying and may increase risk for urinary tract infection and dehydration.
The use of incontinence briefs and frequent toileting will not improve bladder emptying.
A patient with Parkinson's disease has bradykinesia. Which action should the nurse include in the plan of care?
a. Instruct the patient in activities that can be done while lying or sitting.
b. Suggest that the patient rock from side to side to initiate leg movement.
c. Have the patient take small steps in a straight line directly in front of the feet.
d. Teach the patient to keep the feet in contact with the floor and slide them forward.
Rocking the body from side to side stimulates balance and improves mobility. The patient will
be encouraged to continue exercising because this will maintain functional abilities.
Maintaining a wide base of support will help with balance. The patient should lift the feet and
avoid a shuffling gait.
What should the nurse advise a patient with myasthenia gravis (MG) to do?
a. Anticipate the need for weekly plasmapheresis treatments.
b. Complete physically demanding activities early in the day.
c. Protect the extremities from injury due to poor sensory perception.
d. Perform frequent weight-bearing exercise to prevent muscle atrophy.
Muscles are generally strongest in the morning, and activities involving muscle activity
should be scheduled then. Plasmapheresis is not routinely scheduled but is used for
myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is
no decrease in sensation with MG. Muscle atrophy does not occur because although there is
muscle weakness, they are still used.
A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which action should the nurse include in the plan of care?
a. Observe for agitation and paranoia.
b. Assist with active range of motion (ROM).
c. Give muscle relaxants as needed to reduce spasms.
d. Use simple words and phrases to explain procedures.
ALS causes progressive muscle weakness. Assisting the patient to perform active ROM will
help maintain strength as long as possible. Psychotic manifestations such as agitation and
paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the
patient's ability to understand procedures will not be impaired. Muscle relaxants will further
increase muscle weakness and depress respirations.
A 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor. What should the nurse anticipate explaining to the patient?
a. Oral corticosteroids
b. Antiparkinsonian drugs
c. Magnetic resonance imaging (MRI)
d. Electroencephalogram (EEG) testing
The clinical diagnosis of Parkinson's is made when tremor, rigidity, akinesia, and postural
instability are present. The confirmation of the diagnosis is made on the basis of improvement
when antiparkinsonian drugs are administered. MRI and EEG are not useful in diagnosing
Parkinson's disease, and corticosteroid therapy is not used to treat it.
A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which assessment finding should indicate to the nurse that a change in the medication or dosage may be needed?
a. Shuffling gait
b. Tremor at rest
c. Cogwheel rigidity of limbs
d. Uncontrolled head movement
Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or
decrease in dose. The other findings are typical with Parkinson's disease.
Which patient problem should the nurse identify as of highest priority for a patient who has Parkinson's disease and is unable to move the facial muscles?
a. Activity intolerance
b. Inadequate nutrition
c. Disturbed body image
d. Impaired physical mobility
The data about the patient indicate that poor nutrition will be a concern because of decreased
swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's
disease, but the data do not indicate that they are current problems for this patient.
Which assessment should the nurse identify as most important regarding a patient with myasthenia gravis?
a. Pupil size
b. Grip strength
c. Respiratory effort
d. Level of consciousness
Because respiratory insufficiency may be life threatening, it will be most important to monitor
respiratory function. The other data also will be assessed but are not as critical.
After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient reports nausea and severe abdominal cramps. Which action should the nurse take first?
a. Auscultate the patient's bowel sounds.
b. Notify the patient's health care provider.
c. Administer the prescribed PRN antiemetic drug.
d. Give the scheduled dose of prednisone (Deltasone).
The patient's history and symptoms indicate a possible cholinergic crisis. The health care
provider should be notified immediately, and it is likely that atropine will be prescribed. The
other actions will be appropriate if the patient is not experiencing a cholinergic crisis.
After change-of-shift report, which patient should the nurse assess first?
a. Patient with myasthenia gravis who is reporting increased muscle weakness.
b. Patient with a bilateral headache described as "like a band around my head."
c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin).
d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms.
Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse
should assess this patient first. The other patients should be assessed but do not appear to need
immediate nursing assessments or actions to prevent life-threatening complications.
A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which interventions should the nurse include in the plan of care? (Select all that apply.)
a. Provide an elevated toilet seat.
b. Cut patient's food into small pieces.
c. Serve high-protein foods at each meal.
d. Place an armchair at the patient's bedside.
e. Observe for sudden exacerbation of symptoms.
ANS: A, B, D
Because the patient with Parkinson's disease has difficulty chewing, food should be cut into
small pieces. An armchair should be used when the patient is seated so that the patient can use
the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting
on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa.
Parkinson's disease is a steadily progressive disease without acute exacerbations.
After the insertion of an arteriovenous graft in the right forearm, a patient reports pain and coldness of the right fingers. Which action should the nurse take?
a. Remind the patient to take a daily low-dose aspirin tablet.
b. Report the patient's symptoms to the health care provider.
c. Elevate the patient's arm on pillows above the heart level.
d. Teach the patient about normal arteriovenous graft function.
The patient's problems suggest the development of distal ischemia (steal syndrome) and may
require revision of the AVG. Elevating the arm above the heart will further decrease
perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used
to maintain grafts.
Which assessment finding should the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30?
a. Persistent skin tenting
b. Rapid, deep respirations
c. Hot, flushed face and neck
d. Bounding peripheral pulses
Patients with metabolic acidosis caused by AKI may have Kussmaul respirations to eliminate
carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis.
Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in
The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. What will be the primary treatment goal in the plan?
a. Augmenting fluid volume
b. Maintaining cardiac output
c. Diluting nephrotoxic substances
d. Preventing systemic hypertension
The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and
provide supportive care while the kidneys recover. Because this patient's heart failure is
causing AKI, the care will be directed toward treatment of the heart failure. For renal failure
caused by hypertension, hypovolemia, or nephrotoxins, the other responses could be correct.
Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective?
a. "I need to get most of my protein from low-fat dairy products."
b. "I will increase my intake of fruits and vegetables to 5 per day."
c. "I will measure my output each day to help calculate the amount I can drink."
d. "I need erythropoietin injections to boost my immunity and prevent infection."
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.
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. What should the nurse assess before administering the medication?
a. Bowel sounds
b. Blood glucose
c. Blood urea nitrogen (BUN)
d. Level of consciousness (LOC)
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
Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful?
a. Split-pea soup, English muffin, and nonfat milk
b. Poached eggs, whole-wheat toast, and apple juice
c. Oatmeal with cream, half a banana, and herbal tea
d. Cheese sandwich, tomato soup, and cranberry juice
Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese
is high in salt and phosphate, and tomato soup is high in potassium. Split-pea soup is high in
potassium, and dairy products are high in phosphate. Bananas are high in potassium, and
cream is high in phosphate.
A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?
a. Urine volume
b. Creatinine level
c. Glomerular filtration rate (GFR)
d. Blood urea nitrogen (BUN) level
GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based
on factors such as fluid volume status and protein intake. 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.
A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft?
a. A fistula is much less likely to clot.
b. A fistula increases patient mobility.
c. A fistula can be used sooner after surgery.
d. A fistula can accommodate larger needles.
Arteriovenous (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.
Which action will the nurse include in the plan of care to maintain the patency of a patient's left arm arteriovenous fistula?
a. Auscultate for a bruit at the fistula site.
b. Assess the 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.
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.
A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching?
a. Increased calories are needed because glucose is lost during hemodialysis.
b. More protein is allowed because urea and creatinine are removed by dialysis.
c. Dietary potassium is not restricted because the level is normalized by dialysis.
d. Unlimited fluids are allowed because retained fluid is removed during dialysis.
When the patient is started on dialysis and nitrogenous wastes are removed, more protein in
the diet is encouraged. Glucose is not lost during hemodialysis. Fluids are still restricted to
avoid excessive weight gain and complications such as shortness of breath. Sodium and
potassium intake continues to be restricted to avoid the complications associated with high
levels of these electrolytes.
Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?
a. The patient leaves the catheter exit site without a dressing.
b. The patient plans 30 to 60 minutes for a dialysate exchange.
c. The patient cleans the catheter while in the bathtub each day.
d. The patient slows the inflow rate when experiencing abdominal pain.
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.
Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation?
a. The patient has type 1 diabetes.
b. The patient has metastatic lung cancer.
c. The patient has a history of chronic hepatitis C infection.
d. The patient is infected with human immunodeficiency virus.
Disseminated malignancies are a contraindication to transplantation. The conditions of the
other patients are not contraindications for kidney transplant.
The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required?
b. Calcium phosphate
c. Magnesium hydroxide
d. Multivitamin with iron
Since magnesium is excreted by the kidneys, patients with CKD should not use
over-the-counter products containing magnesium. The other medications are appropriate for a
patient with CKD.
What laboratory value should the nurse check before administering captopril to a patient with stage 2 chronic kidney disease?
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 would also be monitored in patients with CKD but
would not affect whether the captopril was given or not.
Which intervention will be included in the plan of care for a patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein?
a. Start continuous pulse oximetry.
b. Restrict the patient's protein intake.
c. Restrict physical activity to bed rest.
d. Discontinue the urethral retention catheter.
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.
A 72-yr-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?
a. Insert urethral catheter.
b. Obtain renal ultrasound.
c. Draw a complete blood count.
d. Infuse normal saline at 50 mL/hr.
The patient's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of an indwelling catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions are appropriate but should be implemented after the catheter.
A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?
a. The creatinine level is 3.0 mg/dL.
b. Urine output over an 8-hour period is 2500 mL.
c. The blood urea nitrogen (BUN) level is 67 mg/dL.
d. The glomerular filtration rate is less than 30 mL/min/1.73 m2.
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.
A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first?
a. Notify the patient's health care provider.
b. Document the QRS interval measurement.
c. Check the patient's most recent potassium level.
d. Review the chart for the patient's current creatinine level.
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 increased in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias.
A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?
a. Insert a urinary retention catheter.
b. Administer epoetin alfa (Epogen).
c. Place the patient on a cardiac monitor.
d. Give sodium polystyrene sulfonate (Kayexalate).
Because hyperkalemia can cause fatal 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.
A patient has arrived for a scheduled hemodialysis session. Which nursing action is appropriate for the registered nurse (RN) to delegate to a dialysis technician?
a. Teach the patient about fluid restrictions.
b. Check blood pressure before starting dialysis.
c. Assess for causes of an increase in predialysis weight.
d. Determine the ultrafiltration rate for the hemodialysis.
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.
A licensed practical/vocational nurse (LPN/VN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention?
a. The LPN/VN assists the patient to ambulate in the hallway.
b. The LPN/VN administers the erythropoietin subcutaneously.
c. The LPN/VN administers the iron supplement and phosphate binder with lunch.
d. The LPN/VN carries a tray containing low-protein foods into the patient's room.
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/VN are appropriate for a patient with
A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly 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's abdomen appears bloated after the inflow.
d. The patient has abdominal pain during the inflow phase.
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.
During routine hemodialysis, a patient reports nausea and dizziness. Which action should the nurse take first?
a. Slow down the rate of dialysis.
b. Check the blood pressure (BP).
c. Review the hematocrit (Hct) level.
d. Give prescribed PRN antiemetic drugs.
The patient's reports of nausea and dizziness suggest hypotension, so the first action should be
to check the BP. The other actions may also be appropriate based on the blood pressure
A patient reports leg cramps during hemodialysis. What action should the nurse take?
a. Massage the patient's legs.
b. Reposition the patient supine.
c. Give acetaminophen (Tylenol).
d. Infuse a bolus of normal saline.
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.
A 74-yr-old patient who is progressing to stage 5 chronic kidney disease asks the nurse, "Do
you think I should go on dialysis?" Which initial response by the nurse is best?
a. "It depends on which type of dialysis you are considering."
b. "Tell me more about what you are thinking regarding dialysis."
c. "You are the only one who can make the decision about dialysis."
d. "Many people your age use dialysis and have a good quality of life."
The nurse should initially clarify the patient's concerns and questions about dialysis. The
patient is the one responsible for the decision, and many people using dialysis do have good
quality of life, but these responses block further assessment of the patient's concerns.
Referring to which type of dialysis the patient might use only indirectly responds to the
After receiving change-of-shift report, which patient should the nurse assess first?
a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange.
b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level.
c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4
d. Patient who has just returned from having hemodialysis with a heart rate of
The patient who has tachycardia after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications. The other patients also need assessments or interventions but are not at risk for life-threatening complications.
Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis? (Select all that apply.)
a. Avoid commercial salt substitutes.
b. Restrict fluid intake to 1000 mL daily.
c. Take phosphate binders with each meal.
d. Choose high-protein foods for most meals.
e. Have several servings of dairy products daily.
ANS: A, C, D
Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is not limited unless weight and blood pressure are not controlled. Dairy products are high in phosphate and usually are limited.
A patient in the oliguric phase after an acute kidney injury has had a 250-mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient's fluid restriction for the next 24 hours?
The general rule for calculating fluid restrictions is to add all fluid losses for the previous 24 hours, plus 600 mL for insensible losses: (250 + 100 + 600 = 950 mL).
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