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The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding?
- A. Fluid retention.
- B. Hemolysis of red blood cells.
- C. Below-normal metabolic rate.
- D. Reduced renal blood flow.
Correct Answer: D
Rationale: Reduced renal blood flow impairs urea excretion, causing elevated BUN levels in acute renal failure.
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The nurse is teaching a client post-appendectomy about activity restrictions. Which instruction is most appropriate?
- A. Avoid lifting more than 10 pounds for 4–6 weeks.
- B. Resume full activity within 1 week.
- C. Avoid walking for at least 2 weeks.
- D. Perform sit-ups to strengthen abdominal muscles.
Correct Answer: A
Rationale: Avoiding lifting more than 10 pounds for 4–6 weeks prevents strain on the surgical site post-appendectomy. Resuming full activity too soon, avoiding walking, or doing sit-ups could impair healing. CN: Physiological adaptation; CL: Synthesize
The client asks the nurse, 'Why can't the doctor tell me exactly how much of my leg they're going to take off? Don't you think I should know that?' The nurse responds, knowing that the final decision on the level of the amputation will depend primarily on:
- A. The need to remove as much of the leg as possible
- B. The adequacy of the blood supply to the tissues
- C. The ease with which a prosthesis can be fitted
- D. The client's ability to walk with a prosthesis
Correct Answer: B
Rationale: The level of amputation depends primarily on the adequacy of blood supply to the tissues, as determined intraoperatively. Sufficient perfusion is necessary for healing and preventing further necrosis. Removing excess tissue, prosthesis fitting, or walking ability are secondary considerations.
A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.
The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) has completed an assessment on a client
Item 1 of 1
Nurses' Notes Orders
1923: Assessment completed. Peripheral vascular access device (PAD) was assessed. Erythema
and swelling were noted at the insertion site. The client reported "severe" pain, and
tenderness was endorsed when it was palpated. The infusion was stopped.
The nurse reviews the assessment and is preparing to take action. For each potential action, click to specify whether the potential action is indicated or not indicated for the client.
- A. Remove the peripheral vascular access device
- B. Obtain an order for phentolamine
- C. Notify the physician
- D. Flush the intravenous vascular access device with 5 mL of 0.9% saline (sodium chloride)
- E. Disconnect administration set
Correct Answer: A,C,F
Rationale: Removing the PVAD, notifying the physician, and disconnecting the administration set are indicated for infiltration; flushing is not indicated, and phentolamine is for extravasation.
A client who has had a total laryngectomy appears withdrawn and depressed. He keeps the curtain drawn, refuses visitors, and indicates a desire to be left alone. Which nursing intervention would have the threshold to be removed.
- A. Discussing his behavior with his wife to determine the cause.
- B. Exploring his future plans.
- C. Respecting his need for privacy.
- D. Encouraging him to express his feelings nonverbally and in writing.
Correct Answer: D
Rationale: Encouraging nonverbal or written expression allows the client to process emotions despite speech loss, addressing psychological needs. Discussing with his wife breaches confidentiality. Exploring future plans may be premature. Respecting privacy may reinforce withdrawal.