Nokea
A nurse is teaching a client who has acute kidney injury (AKI) about the oliguric phase. Which of the following information should the nurse include in the teaching?
- A. The glomerular filtration rate (GFR) recovers.
- B. Urine output is less than 400 mL per 24 hours.
- C. BUN and creatinine levels decrease.
- D. Renal function is reestablished.
Correct Answer: B
Rationale: Oliguria (<400mL/24hr) defines this phase of AKI with impaired urine production.
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The nurse would be most concerned about a prescription for a lipid emulsion for a client with which condition?
- A. Fractured femur
- B. Severe anorexia nervosa
- C. Gastrointestinal obstruction
- D. Chronic diarrhea and vomiting
Correct Answer: C
Rationale: Gastrointestinal obstruction contraindicates lipid emulsion administration as it could worsen the obstruction.
The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client is cause for the greatest concern?
- A. I have a tight sensation in my lower leg when I forget to put my feet up.
- B. I can't button my pants anymore because my belly is so swollen.
- C. I'm very constipated and have been straining during bowel movements.
- D. When I sleep, I have to sit in a recliner so that I can breathe more easily.
Correct Answer: B
Rationale: This indicates new or worsening ascites, a serious complication of portal hypertension requiring evaluation.
A nurse admits a client to the emergency department who reports nausea, vomiting, and epigastric pain that worsens when lying down. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?
- A. Increased serum amylase
- B. Decreased WBC count
- C. Increased serum calcium
- D. Decreased serum lipase
Correct Answer: A
Rationale: Serum amylase rises quickly in acute pancreatitis due to pancreatic inflammation.
A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C?
- A. A client who works in a child care center
- B. A client who eats raw shellfish
- C. A client who has multiple tattoos
- D. A client who has recently traveled to an underdeveloped country
Correct Answer: C
Rationale: Tattoos with non-sterile equipment are a risk factor for HCV transmission.
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?
- A. Provide oral care every 4 hours and as needed
- B. Position the head of the client's bed in the flat position
- C. Turn the client every 4 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct Answer: A
Rationale: Regular oral care reduces bacterial colonization that could lead to VAP.