8. A 78-year-old patient is admitted to the
hospital with dehydration and electrolyte
imbalance. The patient is confused and
incontinent of urine on admission. In developing
a plan of care for the patient, an appropriate
nursing intervention for the patient's incontinence
is to
a. insert an indwelling catheter.
b. apply absorbent incontinent pads.
c. assist the patient to the bathroom q2hr.
d. restrict fluids after the evening meal.: Answer: C
Rationale: In older or confused patients, incontinence may
be avoided by using scheduled toileting times. Indwelling
catheters increase the risk for UTI. Incontinent pads
increase the risk for skin breakdown. Restricting fluids is
not appropriate in a patient with dehydration.
Cognitive Level: Application Text Reference: pp. 1183-
1185
Nursing Process: Planning NCLEX: Physiological Integrity
6. In planning teaching for a patient with benign
nephrosclerosis, the nurse should include
instructions regarding
a. measuring daily intake and output amounts.
b. obtaining and documenting daily weights.
c. monitoring and recording blood pressure.
d. preventing bleeding caused by anticoagulants.:Answer: C
Rationale: Hypertension is the major symptom of
nephrosclerosis. Measurements of intake and output
and daily weights are not necessary unless the patient
develops renal insufficiency. Anticoagulants are not used
to treat nephrosclerosis.
Cognitive Level: Application Text Reference: p. 1175
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
RenalStudy online at quizlet.com/_bwmm8
2. The nurse establishes a nursing diagnosis of
excess fluid volume related to inflammation at
the glomerular basement membrane in a patient
with acute glomerulonephritis. To best evaluate
whether the problem identified in the nursing
diagnosis has resolved, the nurse will monitor for
a. proteinuria.
b. elevated creatinine.
c. periorbital edema.
d. hematuria.: Answer: C
Rationale: Resolution of the excess fluid volume is best
evaluated by changes in edema. The other data may
indicate whether the glomerulonephritis is resolving but do
not provide data about fluid volume.
Cognitive Level: Application Text Reference: p. 1165
Nursing Process: Evaluation NCLEX: Physiological
Integrity
10. A nurse is caring for a client with chronic renal failure.The laboratory
results indicate hypocalcemia and hyperphosphatemia.When
assessing the client, the nurse should be alert for whichof the
following? SELECT ALL THAT APPLY.
1) Trousseau's sign
2) Cardiac arrhythmia
3) Constipation
4) Decreased clotting time
5) Drowsiness and lethargy
6) Fractures: RATIONALE: 1, 2, 6.
Hypocalcemia is a calcium deficit that
causes irritability and repetitive muscle
spasms.
S/S of hypocalcemia include
Trousseau's sign, cardiac arrhythmias,
diarrhea, increased clotting times,
anxiety, and irritability.
The calcium-phosphorus imbalance
leads to brittle bones and pathologic
fractures
5. A patient is admitted to the hospital with
nephrotic syndrome after taking an OTC
nonsteroidal antiinflammatory drug (NSAID) a
week earlier. Which assessment data will the
nurse expect to find related to this illness?
a. Low blood pressure
b. Recent weight gain
c. Poor skin turgor
d. High urine ketones: Answer: B
Rationale: The patient with a rapid-onset nephrotic
syndrome will have rapid weight gain associated with
edema. Hypertension is a clinical manifestation of
nephrotic syndrome. Skin turgor is normal because of the
edema. Urine protein is high.
Cognitive Level: Application Text Reference: p. 1167
Nursing Process: Assessment NCLEX: Physiological
Integrity
9. A patient undergoes a nephrectomy for
massive trauma to the kidney resulting from
a fall from a scaffold. Which assessment data
obtained postoperatively are most important to
communicate to the surgeon?
a. Blood pressure is 102/48.
b. Urine output is 20 ml/hr for 2 hours.
c. Crackles are heard at both lung bases.
d. Incisional pain level is 8/10.: Answer: B
Rationale: Because the urine output should be at least
0.5 ml/kg/hr, a 40-ml output for 2 hours indicates that the
patient may have decreased renal perfusion because
of bleeding, inadequate fluid intake, or obstruction at
the suture site. The blood pressure requires ongoing
monitoring but does not indicate inadequate perfusion at
this time. The patient should cough and deep breathe,
but the crackles do not indicate a need for an immediate
change in therapy. The incisional pain should be
addressed, but this is not as potentially life-threatening
as decreased renal perfusion. In addition, the nurse can
medicate the patient for pain.
Cognitive Level: Application Text Reference: p. 1188
Nursing Process: Assessment NCLEX: Physiological
Integrity
4. A patient who is diagnosed with nephrotic
syndrome has 3+ ankle and leg edema and
ascites. Which nursing diagnosis is a priority for
the patient?
a. Fluid-volume excess related to low serum
protein levels
b. Altered nutrition: less than required related to
protein restriction
c. Activity intolerance related to increased weight
and fatigue
d. Disturbed body image related to peripheral
edema and ascites: Answer: A
Rationale: The patient has massive edema, so the priority
problem at this time is the excess of fluid volume. The
other nursing diagnoses are also appropriate, but the focus
of nursing care should be resolution of the edema and
ascites.
Cognitive Level: Application Text Reference: pp. 1167-
1168
Nursing Process: Diagnosis NCLEX: Physiological Integrity
3. A patient with nephrotic syndrome develops
flank pain. The nurse will anticipate treatment
a. antibiotics.
b. antihypertensives.
c. anticoagulants.
d. corticosteroids.: Answer: C
Rationale: Flank pain in a patient with nephrosis suggests
a renal vein thrombosis, and anticoagulation is needed.
Antibiotics are used to treat a patient with flank pain
caused by pyelonephritis. Antihypertensives are used if
the patient has high blood pressure. Corticosteroids may
be used to treat nephrotic syndrome but will not resolve a
thrombosis.
Cognitive Level: Application Text Reference: p. 1175
Nursing Process: Planning NCLEX: Physiological Integrity1. When admitting a patient with acute
glomerulonephritis, the nurse will ask the patient
about
a. history of high blood pressure.
b. frequency of UTIs.
c. recent sore throat and fever.
d. family history of kidney disease.: Answer: C
Rationale: Acute glomerulonephritis frequently occurs
after a streptococcal infection such as strep throat. It is not
caused by hypertension, UTI, or related to family history.
Cognitive Level: Application Text Reference: p. 1165
Nursing Process: Assessment NCLEX: Physiological
7. When obtaining the health history for a
30-year-old patient who smokes two packs of
cigarettes daily, the nurse will plan to do teaching
about the increased risk for
a. interstitial cystitis.
b. UTI.
c. kidney stones.
d. bladder cancer.: Answer: D
Rationale: Cigarette smoking is a risk factor for bladder
cancer. The patient's risk for developing interstitial cystitis,
UTI, or kidney stones will not be reduced by quitting
smoking.
Cognitive Level: Application Text Reference: p. 1178
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
Renal
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