NursGuru

    Exam Review

    1. A nurse is assessing a client diagnosed with end-stage renal disease (ESRD) that is receiving hemodialysis. Which of the following findings should the nurse identify as an indication that the client is experiencing fluid overload?
      A)
      Return of skin to previous position when the client's shin is palpated
      B)
      Oxygen saturation 93%
      C)
      The client has gained 1 pound since yesterday.
      D)
      Distended neck veins
    2. A client has been admitted to a burn intensive care unit with extensive full thickness burns over 36% of the body. After ensuring cardiopulmonary stability, which should be the nurse's highest priority when planning the client's care in the early acute phase of the injury?
      A)
      Mitigating risk of infection
      B)
      Provide nutritional support
      C)
      Adequate fluid resuscitation
      D)
      Assessing psychosocial coping
    3. A nurse is assessing a client who has an electrical burn. Which of the following cues should the nurse recognize as indicating a potential complication of the burn injury?
      A)
      Cool and clammy skin
      B)
      Irregular heart rhythm
      C)
      Purulent drainage from the burn site
      D)
      Muscle weakness
    4. A nurse is assessing a client with a burn injury. The client is experiencing hoarseness, a brassy cough, and drooling. The nurse recognizes these findings as indicative of which of the following?
      A)
      Carbon monoxide poisoning
      B)
      Pulmonary edema
      C)
      Bacterial pneumonia
      D)
      Inhalation injury

    Exam Review

    1. A nurse has admitted a client with burns to the head, face, and hands. On initial assessment, wheezing is noted. On reassessment, the nurse notes decreased bilateral lung sounds. The client appears anxious, respiration rate is 30, and Pulse oximetry is 80%. Which of the following is the priority action the nurse should take?
      A)
      Document the change and continue to monitor the client's respiratory rate.
      B)
      Encourage the client to cough and auscultate the lungs again.
      C)
      Reposition the client in high-Fowler's position and reassess breath sounds.
      D)
      Notify the health care provider and prepare for endotracheal intubation.
    2. A nurse is reviewing laboratory values of a client with chronic renal failure and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?
      A)
      Encouraging the client to eat bananas.
      B)
      Administering a potassium-sparing diuretic.
      C)
      Initiating an IV potassium infusion.
      D)
      Administering sodium polystyrene sulfonate.
    3. A nurse is teaching a client diagnosed with chronic kidney disease (CKD) about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)
      (SATA)
      A)
      Asparagus
      B)
      Tomatoes
      C)
      Raisins
      D)
      Green beans
      E)
      Bananas
    4. A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?
      A)
      Auscultate the antecubital fossa using a Doppler stethoscope.
      B)
      Auscultate the site for a bruit.
      C)
      Check the brachial and radial pulses of the left arm simultaneously.
      D)
      Measure the client's blood pressure to ensure it is higher in the left arm than the right.

    Exam Review

    1. A nurse is assessing a client in the oliguric phase of acute kidney injury (AKI). Which of the following findings should the nurse expect?
      A)
      Hyperkalemia
      B)
      Hypomagnesaemia
      C)
      Decreased creatinine level
      D)
      Increased glomerular filtration rate (GFR)
    2. A nurse is caring for a client diagnosed with end-stage renal disease (ESRD) that reports having shortness of breath and swelling in the lower extremities. The nurse assesses that the client has crackles in the lungs and an elevated blood pressure. The nurse should suspect which of the following conditions based on the client's symptoms?
      A)
      Hyperkalemia
      B)
      Hypoxemia
      C)
      Hypervolemia
      D)
      Hypovolemia
    3. A nurse is assessing a client diagnosed with chronic renal disease for fluid volume excess. The nurse should recognize that which of the following provides a reliable measure of fluid retention?
      A)
      Tissue edema
      B)
      Urinary output
      C)
      Daily weight
      D)
      Sodium level
    4. A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. The nurse recognizes that which pain management strategy should best meet this client's pain control needs?
      A)
      Distraction and relaxation techniques
      B)
      A patient-controlled analgesia (PCA) system
      C)
      A combination of benzodiazepines and topical anaesthetics
      D)
      The use of oral opioids

    Exam Review

    1. A nurse is assessing a client who has sustained burns on the entire left arm and the anterior chest. Using the rule of nines, the nurse calculates what percentage of total body surface area is affected by the burns?
      A)
      36%
      B)
      27%
      C)
      9%
      D)
      18%
    2. The nurse is caring for a client with superficial partial thickness burn injuries to the upper and lower extremities. The client is ordered IV morphine for pain. The nurse recognizes that narcotics are given IV during the initial management of pain based on which on which of the following rationales?
      A)
      Damaged tissue and edema may interfere with drug absorption via other routes.
      B)
      The client can experience nausea and vomiting when given oral medications.
      C)
      Pain resulting from a burn injury requires relief by the fastest route available.
      D)
      Bleeding may occur at injection sites when the intramuscular route is used.
    3. A nurse is planning meals for a client diagnosed with chronic kidney disease (CKD). The nurse should recognize that which dietary choices are appropriate for the client?
      A)
      Carrots and spinach
      B)
      Cold cuts with bun and fresh pears
      C)
      Spaghetti and meat sauce with a breadsticks
      D)
      Hamburger on a bun and a banana
    4. A nurse has accepted care of a client with a major burn injury. The burns are 2nd and 3rd degree and estimated at 45% of total body surface area (TBSA). In addressing the pathophysiologic changes resulting from major burns the nurse is aware that the priority intervention for this client is?
      A)
      Maintain adequate IV hydration
      B)
      Prepare intramuscular pain medications
      C)
      Give IV potassium chloride
      D)
      Administer broad-spectrum antibiotics

    Exam Review

    1. A nurse is reviewing laboratory findings of a client admitted to the unit. The nurse recognizes that which of the following results indicates acute kidney injury?
      A)
      Hemoglobin 16 g/dL
      B)
      Serum creatinine 6 mg/dL
      C)
      BUN 15 mg/dL
      D)
      Serum potassium 4.5 mEq/L
    2. A nurse is preparing a client for the operating room. A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following interventions should the nurse include in the plan? (Select all that apply)
      A)
      Verify informed consent
      B)
      Administer diphenhydramine (Benadryl) prior to procedure.
      C)
      Obtain coagulation studies
      D)
      Collect a urine specimen prior to procedure
      E)
      Ensure NPO status
    3. A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?
      A)
      Skin has a leathery and dry
      B)
      Skin is intact, dry, and red in color
      C)
      Skin is red, blanches, and weeps
      D)
      Skin is waxy in appearance
    4. A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?
      A)
      Hyperkalemia
      B)
      Hypercalcemia
      C)
      Hypophosphatemia
      D)
      Hypernatremia

    Exam Review

    1. A nurse is caring for a client receiving a hemodialysis treatment. Which of the following complications should the nurse recognize when the client becomes restless and reports nausea and headache?
      A)
      Air embolism
      B)
      Septic shock
      C)
      Disequilibrium syndrome
      D)
      Acute hemolysis
    2. A nurse is caring for a client receiving sodium polystyrene sulfonate (Kayexalate) for the treatment of chronic renal disease. The nurse should monitor for which therapeutic effect of sodium polystyrene sulfonate (Kayexalate)?
      A)
      Decreased urine specific gravity
      B)
      Decreased serum potassium
      C)
      Decreased serum sodium
      D)
      Decreased serum phosphorus
    3. A nurse is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
      A)
      "Incisions will be made in the burnt tissues to improve circulation."
      B)
      "This procedure involves placing the client into a Whirlpool tub and removing the dead tissue."
      C)
      "A piece of healthy skin will be removed from an unburned area and grafted over the burned area."
      D)
      "Dead tissue will be non-surgically removed."
    4. A 65-year-old patient is admitted to the hospital with complaints of decreased urine output, fatigue, and swelling in the legs. Which of the following clinical cues is most indicative of acute kidney injury?
      A)
      Hyperglycemia
      B)
      Elevated serum creatinine levels
      C)
      Increased urine output
      D)
      Increased appetite