Nokea
The oncoming nurse learns that her new patient is suffering from Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion. Which of the following nursing actions is the most important?
- A. Assess the patient's mental status
- B. Provide oral hygiene
- C. Keep accurate intake and output measurements
- D. Reduce stress and discomfort
Correct Answer: A
Rationale: SIADH causes hyponatremia, which can lead to neurological changes, making mental status assessment critical.
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The nurse is administering phosphate excreting medications to a client with hypocalcemia. The reason for administering this medication is because
- A. as phosphorus exits the body so does calcium.
- B. calcium is managed by the excretion of phosphorus.
- C. when serum phosphorus decreases, serum calcium increases.
- D. phosphorus must be above 4.5 mg/dL (1.45 mmol/L) [3.0-4.5 mg/dL,0.81-1.58 mmol/L] before calcium can increase.
Correct Answer: C
Rationale: Phosphate-excreting medications reduce serum phosphorus levels, which inversely increases serum calcium levels due to the physiological relationship between phosphorus and calcium. Options A, B, and D are incorrect as they misrepresent this relationship.
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 following scenario applies to the next 1 items
The medical-surgical nurse is caring for a 67-year-old client
Item 1 of 1
Nurses’ Note
1535: Client returned from hemodialysis via stretcher to assigned room. The client was alert, oriented x 4. Denied any pain. He stated he felt ‘tired and dizzy.’ The client reported that the dizziness occurred when he quickly changed positions. The client was assessed, and vital signs were obtained.
Vital Signs
• Temperature 97° F (36° C)
• Pulse 94/minute; irregular
• Respirations 14/minute
• Blood Pressure 91/58 mm Hg
• Oxygen saturation 92% on room air
Assessment
Neurological:
Alert and completely oriented; reports dizziness. Pupils, equal, round, and reactive to light.
Cardiovascular:
Peripheral pulses intact; no edema; S1/S2 heart tones. Positive bruit and thrill in left arm A/V fistula. Gauze dressing applied which is dry with a scant amount of dry blood
Respiratory:
Diminished lung sounds, occasional cough
GI/GU:
Normoactive bowel sounds in all quadrants. Anuria.
Skin:
Warm and dry
Medical History
• End-stage renal disease (ESRD)
• Uncontrolled hypertension
• Chronic obstructive pulmonary disease
• Atrial fibrillation
The nurse reviews the nursing note, vital signs, assessment, and medical history. Which clinical data is most concerning to the nurse? Select all that apply.
- A. A/V fistula assessment
- B. Oxygen saturation
- C. Pulse
- D. Blood pressure
- E. Neurological assessment
- F. Temperature
- G. Anuria
Correct Answer: C,D,E,G
Rationale: Irregular pulse, low blood pressure (91/58 mmHg), dizziness, and anuria indicate potential cardiovascular and renal complications post-hemodialysis.
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 is caring for a client with end-stage renal disease who receives prescribed sevelamer. Which of the following findings would indicate a therapeutic response?
- A. Decreased serum calcium levels
- B. Increased hemoglobin and hematocrit
- C. Decreased serum potassium levels
- D. Decreased serum phosphorus levels
Correct Answer: D
Rationale: Sevelamer is a phosphate binder used to lower serum phosphorus levels in end-stage renal disease, making decreased phosphorus levels the therapeutic response. It does not directly affect calcium (A), hemoglobin/hematocrit (B), or potassium (C).