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What is the most common cause of acute renal failure?
- A. Shock
- B. Nephrotoxic drugs
- C. Enlarged prostate
- D. Diabetes
Correct Answer: A
Rationale: The correct answer is 'Shock.' Acute renal failure is commonly caused by inadequate blood flow to the kidneys, which can occur in cases of shock. This leads to decreased kidney function and potential kidney damage. While nephrotoxic drugs can also cause acute renal failure, shock is the primary and most common cause. An enlarged prostate may lead to obstructive uropathy but is not the most prevalent cause of acute renal failure. Diabetes is typically associated with chronic kidney disease rather than acute renal failure.
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What essential assessment must be performed for clients with implanted dialysis access devices?
- A. Color and capillary refill
- B. Patency and pulse
- C. Thrill and bruit
- D. Trousseau's and temperature
Correct Answer: C
Rationale: Correct! When assessing clients with implanted dialysis access devices, it is crucial to palpate for the thrill, which indicates blood flow, and auscultate for the bruit, a humming sound, to ensure the patency of the access device. Choices A, B, and D are incorrect as they are not specific assessments related to dialysis access devices. Checking color and capillary refill, pulse, Trousseau's sign, and temperature are important assessments in other contexts but not specifically for monitoring implanted dialysis access devices.
A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).
- A. Weight gain
- B. Fatigue
- C. Bloody sputum
- D. Diaphoresis during sleep
Correct Answer: A
Rationale: The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.
The client is cared for by a nurse and calls for the nurse to come to the room, expressing feeling unwell. The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next?
- A. Administer PRN anxiolytic
- B. Administer Antibiotics
- C. Reassure the client that everything is okay and offer food and beverage
- D. Determine the Glasgow Coma Scale
Correct Answer: A
Rationale: Correct! The client's vital signs indicate tachycardia and tachypnea, which could be indicative of hypoxia. Administering a PRN anxiolytic would not address the underlying issue and could mask deterioration. Reassuring the client without further assessment or intervention could lead to a delay in appropriate care if there is a serious underlying cause for the symptoms. Determining the Glasgow Coma Scale is not relevant to the client's presenting symptoms of feeling unwell and suspecting something is wrong, coupled with abnormal vital signs.
When dressing a severe burn to the right hand, it is important for the nurse to:
- A. Apply a wet-to-dry dressing for debridement
- B. Wrap each digit individually to prevent webbing
- C. Open blisters to allow drainage prior to dressing
- D. Allow the client to do as much of the dressing change as possible
Correct Answer: B
Rationale: When dressing a severe burn to the hand, it is crucial to wrap each digit individually to prevent webbing, which can lead to contractures and impaired function. Applying a wet-to-dry dressing for debridement is not recommended for burn wounds as it can cause trauma to the wound bed during removal. Opening blisters can increase the risk of infection and delay healing. Allowing the client to perform the dressing change may not ensure proper care and can lead to complications.
What is the most common cause of acute renal failure?
- A. Shock
- B. Nephrotoxic drugs
- C. Enlarged prostate
- D. Diabetes
Correct Answer: A
Rationale: The most common cause of acute renal failure is shock. In cases of shock, such as hypovolemic shock where there is low blood volume, the kidneys receive inadequate blood flow leading to acute renal failure. This can result in the kidneys starting to die within 20 minutes of low pressure. While nephrotoxic drugs can also cause acute renal failure, shock is more commonly associated with this condition. An enlarged prostate can lead to urinary retention but is not the most common cause of acute renal failure. Diabetes, on the other hand, can cause chronic kidney disease over time but is not typically the primary cause of acute renal failure.