Nokea
The nurse is teaching a client with hypercalcemia appropriate dietary measures. Which food selections by the client would require follow-up by the nurse? Select all that apply.
- A. broccoli
- B. 2% milk
- C. whole wheat pasta
- D. bananas
- E. seafood
Correct Answer: B
Rationale: Milk is high in calcium and should be limited in hypercalcemia to prevent worsening the condition.
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The nurse is preparing to admit a client with chronic kidney disease and congestive heart failure. Which assessment would most effectively determine the client's fluid balance?
- A. Daily weight
- B. Intake and output measurement
- C. Urine specific gravity
- D. Serum sodium level
Correct Answer: A
Rationale: Daily weight is the most effective way to assess fluid balance, reflecting changes in fluid status.
The nurse is assessing a client with an acute kidney injury (AKI). Which of the following findings would support a diagnosis of AKI?
- A. hypernatremia
- B. metabolic alkalosis
- C. oliguria
- D. hypokalemia
Correct Answer: C
Rationale: Oliguria is a hallmark of AKI due to reduced kidney perfusion and filtration.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 78-year-old female client
Item 1 of 1
Nurses' Note
1355: Client was brought to the ED by the client's adult children, who reported that while she was visiting, she reported dizziness and seemed slightly confused. The adult child reports that the symptoms started one day ago. The client recently had a change in her blood pressure medication, with the physician increasing the dosage of her prescribed furosemide. Medical history of hypertension, hyperlipidemia, and osteoarthritis. Vital signs: T 100° F (37.8° C), P 104, RR 22, BP 110/66, pulse oximetry reading 95% on room air.
On assessment, the client is lethargic and oriented to person and place, but not time. The client's breathing appears unlabored with tachypnea. Clear lung sounds throughout all lung fields. Skin is warm, dry, and flaky. Peripheral pulses 1+ in all extremities. Aching pain reported in the hips and knees and rated 5 on a scale of 0 (no pain) to 10 (severe pain). Client was ambulated to the bathroom, where she urinated 300 mL of clear, yellow urine without any odor or particulates. 22-gauge peripheral venous access device (VAD) placed in right forearm.
Complete the sentence below by choosing from the list of options. Based on the client's..... and............. this client is at highest risk for........
- A. lung sounds
- B. vital signs
- C. pain level
- D. dosage increase of diuretic
- E. urinary infection.
- F. fluid volume deficit.
Correct Answer: B, D,F
Rationale: Increased furosemide dosage increases the risk of fluid volume deficit, as evidenced by dizziness and lethargy.
The nurse preceptor is orienting a newly hired nurse caring for a client with advanced polycystic kidney disease (PKD). Which of the following actions by the newly hired nurse would require follow-up by the nurse preceptor?
- A. Requesting a prescription for ketorolac to help relieve the client's pain.
- B. Instructing the client on how to use guided imagery as a comfort strategy.
- C. Applying dry heat to the client's abdomen or flank for pain relief.
- D. Provides the client with foods high in fiber and low in salt.
Correct Answer: A
Rationale: Ketorolac, an NSAID, can worsen renal function in PKD and requires follow-up.
The nurse has taught a client about a scheduled intravenous (IV) urography (pyelogram). Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I should expect a temporary urinary catheter inserted during the procedure.
- B. I will take a laxative the night before to clear my bowels.
- C. I must fill my bladder with water immediately before the procedure.
- D. I may experience blood in my urine for a few days after this procedure.
Correct Answer: B
Rationale: A laxative is often required before IV urography to clear the bowels for better imaging.