Nokea
When performing a physical assessment, which sensation would the nurse expect to detect when palpating the site of the arteriovenous fistula?
- A. A pulse
- B. A bruit
- C. A thrill
- D. A click
Correct Answer: C
Rationale: A thrill, a buzzing sensation, is expected when palpating a functioning arteriovenous fistula, indicating proper blood flow.
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Which comment is the best response the nurse can offer?
- A. You're a very nice person.
- B. You're a very nice person.
- C. You should expect this at your age.
- D. You're discouraged right now.
Correct Answer: D
Rationale: Acknowledging the client's feelings of discouragement validates their emotional state and opens the door for supportive communication.
The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is most important for the nurse to ask during the admission interview?
- A. Have you recently traveled outside the United States?
- B. Did you recently begin a vigorous exercise program?
- C. Is there a chance you have been exposed to a virus?
- D. What over-the-counter medications do you take regularly?
Correct Answer: D
Rationale: Acute renal failure can be caused by nephrotoxic agents, including over-the-counter medications like NSAIDs. Asking about medication use identifies potential causes of ARF, which is more directly relevant than travel, exercise, or viral exposure.
The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply.
- A. Place the solution on an IV pump at the prescribed rate.
- B. Monitor blood glucose every six (6) hours.
- C. Weigh the client weekly, first thing in the morning.
- D. Change the IV tubing every three (3) days.
- E. Monitor intake and output every shift.
Correct Answer: A,B,E
Rationale: TPN requires an IV pump for precise delivery, frequent glucose monitoring due to high dextrose content, and intake/output monitoring to assess fluid balance. Weekly weights and tubing changes every 3 days are less critical or incorrect.
The nurse is caring for clients on a renal surgery unit. After the afternoon report, which client should the nurse assess first?
- A. The male client who just returned from a CT scan who states he left his glasses in the x-ray department.
- B. The client who is one (1) day postoperative and has a moderate amount of serous drainage on the dressing.
- C. The client who is scheduled for surgery in the morning and wants an explanation of the operative procedure before signing the permit.
- D. The client who had ileal conduit surgery this morning and has not had any drainage in the drainage bag.
Correct Answer: D
Rationale: No drainage in the ileal conduit bag post-surgery suggests obstruction or complications, risking urine backup and renal damage. This is critical. Lost glasses, serous drainage, and surgical education are less urgent.
Which nursing assessment is most important before beginning bladder retraining for this client?
- A. Recording the times at which the client is incontinent
- B. Checking the specific gravity of the urine
- C. Beginning the client's incontinence pad
Correct Answer: A
Rationale: Recording the times of incontinence helps establish a pattern, which is critical for developing an effective bladder retraining schedule tailored to the client's needs.