BIOLOGY 102. Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition CHAPTER 29

Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

CHAPTER 29

Chapter 29

1. The nurse assessing a client newly admitted to the medical–surgical unit with glomerulonephritis expects to find which of the following classic manifestations of this disorder?

1. 1. Acute flank pain, nausea, and vomiting
   2. Hematuria, proteinuria, and edema
   3. Headache, fever, dehydration
   4. Weight loss, anemia, and fatigue

1. The nursing diagnosis established for a client with acute glomerulonephritis is Fluid Volume, Excess related to plasma protein deficit and sodium and water retention. Which of the following assessments provides the most accurate indication of fluid balance for this client?

1. 1. Daily weight
   2. Intake and output records
   3. Serum sodium levels
   4. Vital signs

1. A client returns to the medical–surgical unit following a right nephrectomy, and is receiving oxygen via nasal cannula at a rate of 2 l/minute. The nurse assesses the following: respiratory rate 12/minute, shallow breathing with inadequate lung expansion, and client complaint of shortness of breath. Which nursing intervention has the highest priority at this time?

1. 1. Continue to monitor vital signs and respiratory status.
   2. Encourage the client to deep-breathe and use an incentive spirometer.
   3. Increase oxygen flow rate to at least 5 l/minute.
   4. Position the client with HOB elevated 15 degrees.

1. The nurse evaluates the therapeutic effect of the drug sodium polystyrene sulfonate (Kayexalate) in a client in chronic renal failure by assessing whether which of the following is present?
   1. Decreased serum potassium.
   2. Increased stool excretion
   3. Decreased serum sodium
   4. Increased urine-specific gravity

1. Which of the following laboratory data does the nurse anticipate for the client with chronic renal failure prior to hemodialysis?

1. 1. Increased urine osmolality
   2. Decreased phosphorus
   3. Decreased potassium
   4. Increased creatinine

1. The nurse administering calcium acetate two tablets p.o. with each meal to the client with chronic renal failure understands the rationale for this treatment as which of the following?

1. 1. Decreases serum creatinine.
   2. Lowers serum phosphate.
   3. Neutralizes gastric acid.
   4. Stimulates appetite.

1. The nursing diagnosis established for the client in chronic renal failure (CRF) is Injury, Risk for related to significant osteodystrophy. Which of the following is the most appropriate outcome for this client?

1. 1. Absence of bone fractures
   2. Decreased joint deformities
   3. Increased intake of dietary calcium
   4. Increased exercise tolerance

1. The nurse notes the presence of a cloudy dialysate return for a client in acute renal failure receiving peritoneal dialysis. Which of the following actions does the nurse initiate after notifying the physician?

1. 1. Culture the dialysate return.
   2. Chart the cloudy dialysate.
   3. Measure abdominal girth.
   4. Slow dialysate instillation.

1. The nurse plans to reinforce dietary teaching for the client in renal failure, emphasizing that protein foods selected should be those that are complete proteins, having high biological value. Which of the following foods will the nurse explain meet this criteria?

1. 1. Eggs
   2. Legumes
   3. Nuts
   4. Vegetables

1. Which of the following assessments made by the nurse on a client that has a left forearm arteriovenous (AV) fistula indicates that the fistula is patent?

1. 1. Increase in vein size in the forearm
   2. Hand that is cold to the touch
   3. Presence of an audible bruit
   4. Radial pulse that is palpable

CHAPTER 30

1. A priority nursing assessment prior to a client having a CT (computed tomography) scan with contrast of the chest would include noting:

a. A history of claustrophobia.

b. A history of smoking.

c. Allergies to iodine or seafood.

d. A history of tuberculosis.

2. When a client is diagnosed with Marfan’s syndrome, routine follow-up appointments are important to assess for serious effects on which body system?

a. Musculoskeletal

b. Cardiovascular

c. Urinary

d. Gastrointestinal

Analysis; Implementation; Health Promotion and Maintenance

3. When doing a thorough cardiac history assessment on a client, it would be important to document which of the following statements regarding rest practices? Select all that apply.

a. “I sleep in the recliner.”

b. “I use three pillows when I sleep.”

c. “I still wake up at 7:00 a.m. each day.”

d. “I sleep 5–6 hours at night.”

4. A 75-year-old client reports having to rest between activities during the day. Which effect of aging on the cardiovascular system would best explain this?

a. Decreased cardiac output

b. Increased blood pressure

c. An elongated and dilated aorta

d. Increased stroke volume

5. The nurse is completing a physical exam focused on the cardiovascular system of a client. When an increased pulsation is palpated at the aortic area, this could indicate:

a. A thrill.

b. The apical impulse.

c. A cardiomyopathy.

d. An aortic aneurysm.

6. A client’s radial pulse is palpated simultaneously while auscultating the apical pulse. The radial pulse is felt after the apical pulse is heard. This finding would be considered:

a. A common finding.

b. A pulse deficit.

c. A dysrhythmia.

d. A murmur.

7. When auscultating cardiac sounds, the nurse decided to listen for S1 first. The best location to auscultate this would be at the:

a. Pulmonary valve.

b. Aortic valve.

c. Base.

d. Apex.

8. A murmur has been auscultated on a client during a nursing assessment. The nurse goes back to palpate the area where the murmur was heard. This is done to:

a. Help diagnose the type of murmur.

b. Determine any thrill at the site.

c. Determine how strong the murmur is.

d. Palpate for an aneurysm.

9. A lipid profile is ordered for a client with a cardiac disorder. Nursing care would include:

a. Teaching that no food or fluids except water should be consumed 12 hours prior to the test.

b. No special preparation is needed.

c. Caffeine should be avoided for 24 hours prior to the test.

d. No food or fluids should be consumed 6 hours prior to the test.

10. Following a pericardiocentesis, the nurse would anticipate which client response?

a. Increased heart rate

b. Decreased heart rate

c. Decreased blood pressure

d. Increased blood pressure