Chapter 26 My Nursing Test Banks

 

Wagner, High Acuity Nursing, 6e
Chapter 26

Question 1

Type: MCSA

A patient who has acute kidney injury and who weighs 90 kg had a urine output of 25 mL over the last 12 hours. The nurse would place this patient in which RIFLE category?

1. Injury

2. Risk

3. Failure

4. Loss

Correct Answer: 3

Rationale 1: The injury level of RIFLE criteria is urine output less than 0.5mL/kg for 12 hours. This patients output is lower than that level.

Rationale 2: The risk level of RIFLE criteria is urine output less than 0.5 mL/kg for 6 hours. This patients output is lower than that level.

Rationale 3: According to the RIFLE criteria, failure is a urine output of less than 0.3 ml per kg of body weight or anuria for 12 hours. The patients urine output over the last 12 hours has been 25 mL, which would be comparable to the failure category within the RIFLE criteria.

Rationale 4: Loss is considered a complete loss of renal function for at least 4 weeks.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-2

Question 2

Type: MCSA

An elderly patient is scheduled for a CT scan with contrast. The nurse would anticipate preprocedure administration of which medication to help prevent renal damage?

1. N-acetylcysteine

2. Vitamin B12

3. Intravenous infusion of 5% dextrose

4. Vitamin D

Correct Answer: 1

Rationale 1: Since the use of contrast dyes can be nephrotoxic, steps must be taken to minimize nephrotoxicity. N-acetylcysteine may be given orally or intravenously before contrast administration. N-acetylcysteine acts as a free radical scavenger, counteracts vasoconstriction from contrast agents, and indirectly exhibits cytoprotective effects.

Rationale 2: Vitamin B12 does not offer kidney protection from contrast dyes.

Rationale 3: Since the use of contrast dyes can be nephrotoxic, steps must be taken to minimize nephrotoxicity. The patient should be adequately hydrated with sodium chloride.

Rationale 4: Vitamin D does not provide kidney protection from contrast dyes.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26-1

Question 3

Type: MCMA

A patients acute kidney injury is suspected of being of postrenal etiology. Which medical history would support this diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has been taking NSAIDs for arthritis pain.

2. The patient was diagnosed with heart failure last week.

3. The patient reports having the flu with vomiting and diarrhea for the last 6 days.

4. The patient has large renal calculi in the kidney and ureter.

5. The patient was just diagnosed with prostate cancer.

Correct Answer: 4,5

Rationale 1: The intake of NSAIDs for arthritis would contribute to an intrinsic cause for an acute kidney injury.

Rationale 2: The diagnosis of heart failure would be considered a prerenal cause for an acute kidney injury.

Rationale 3: Vomiting and diarrhea for the last 6 days is considered a prerenal cause for an acute kidney injury.

Rationale 4: Large renal calculi in the kidney and ureter are considered a mechanical cause for a postrenal acute kidney injury since they affect urine drainage from the kidney.

Rationale 5: Prostate cancer can cause obstruction of the urethra, which can result in postrenal acute renal failure.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-1

Question 4

Type: MCSA

A patients serum creatinine level is increasing, but the urine creatinine clearance is decreasing. How would the nurse evaluate these two findings?

1. The patient may be experiencing the onset of heart failure.

2. The patient will probably have associated hypokalemia.

3. The patient is malnourished.

4. There is a decrease in glomerular function.

Correct Answer: 4

Rationale 1: These two laboratory values would not be indicative of heart failure.

Rationale 2: There is no reason to assume that a patient with these two laboratory findings would also be hypokalemic.

Rationale 3: Malnutrition cannot be diagnosed with these two findings.

Rationale 4: Creatinine is the end-product of muscle metabolism and is released into the blood at a constant rate. Creatinine is larger in size compared to urea and is not reabsorbed back into the blood, but is eliminated at a rate related to the level of renal function. For this reason, it is a more reliable measure of the state of renal health. A decrease in the urinary creatinine clearance rate indicates a decrease in glomerular function. A rise in serum creatinine level also indicates a decrease in glomerular functioning.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-2

Question 5

Type: MCSA

A patient with reduced glomerular filtration has a blood pressure of 168/100 mm Hg. The nurse suspects which pathophysiological effect is occurring?

1. Rebound hypertension due to fluid volume deficit

2. Sluggish response by the renin-angiotensin system

3. Kidneys hyper-excreting hydrogen ions

4. Increased renin production causing the retention of water and electrolytes

Correct Answer: 4

Rationale 1: The patient has fluid volume excess and not deficit.

Rationale 2: In the presence of renal ischemia, the renin-angiotensin system is triggered and not sluggish.

Rationale 3: The kidneys are not able to excrete hydrogen ions or hyper-excreting hydrogen ions.

Rationale 4: Hypertension is a common manifestation of renal failure. It is caused by systemic and central fluid volume excess and increased renin production. In the presence of renal ischemia, the renin-angiotensin system is triggered.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-2

Question 6

Type: MCSA

A patient with acute kidney injury is demonstrating signs of gastrointestinal bleeding. The nurse would explain this bleeding to be secondary to which event?

1. Low creatinine level

2. Elevated potassium level

3. Increased ammonia level

4. Low calcium level

Correct Answer: 3

Rationale 1: Gastrointestinal bleeding in the patient with an acute kidney injury is not due to low creatinine level.

Rationale 2: Elevated potassium level results in cardiac dysrhythmia, not gastrointestinal bleeding.

Rationale 3: Electrolyte imbalances and increasing levels of uremic toxins are the primary contributors to gastrointestinal manifestations. As urea decomposes in the gastrointestinal tract, it releases ammonia. Ammonia in the gastrointestinal tract increases capillary fragility and gastrointestinal mucosal irritation resulting in small mucosal ulcerations and the potential for pain, decreased appetite, and gastrointestinal bleeding.

Rationale 4: Low calcium levels do not cause gastrointestinal bleeding.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-2

Question 7

Type: MCSA

A patient with acute kidney injury has a hemoglobin level of 9.0 mg/dL. How would the nurse explain this change to the patient?

1. Your kidneys may not be making enough of a hormone that is required to build red blood cells.

2. Since you are retaining so much fluid, your blood is more dilute.

3. I am afraid you may have some bleeding we have not found as of yet.

4. Your lungs are not exchanging oxygen as well as they should, so your body is not producing hemoglobin.

Correct Answer: 1

Rationale 1: The kidneys produce erythropoietin in response to decreased oxygen delivery to the kidneys. Erythropoietin is necessary for red blood cell production and also plays a role in maintaining healthy endothelium, which promotes angiogenesis and anti-apoptosis. When kidney function deteriorates, red blood cell production is compromised and the life span of the existing red blood cells may decrease.

Rationale 2: When the nurse is explaining pathophysiological events to the patient, every effort should be made to provide accurate information that helps the patient understand changes. The statement about more dilute blood does explain a change in hemoglobin, but it might explain a change in hematocrit.

Rationale 3: It is unlikely that this low hemoglobin is related to undiagnosed bleeding. It is premature to worry a patient about that occurrence.

Rationale 4: There is no indication that this patients lungs are not exchanging oxygen well. Problems with oxygenation would increase hemoglobin levels.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-2

Question 8

Type: MCSA

The nurse is transferring to a high-acuity unit where many patients receive intermittent hemodialysis. Which patient characteristic would the nurse expect?

1. Patients whose hemodynamic status requires slow removal of waste products

2. Patients whose kidney injury will resolve since intermittent dialysis is only done temporarily

3. Patients whose blood pressure and heart rate can be stabilized

4. Patients who have few imbalances in electrolyte levels

Correct Answer: 3

Rationale 1: Intermittent hemodialysis will result in rapid removal of waste products.

Rationale 2: Intermittent hemodialysis may be performed temporarily or the patient may require intermittent dialysis on an outpatient basis for life.

Rationale 3: Even though intermittent hemodialysis provides more efficient and effective clearance of excess fluids and solutes, it is destabilizing to the hemodynamic and electrolyte status of the patient. The patient receiving intermittent hemodialysis will need to have a stable blood pressure and heart rate.

Rationale 4: One of the indications for intermittent dialysis is to balance electrolyte levels. There is no indication that this will be successful only if the patient has few imbalances.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26-4

Question 9

Type: MCMA

A patient is scheduled for arteriovenous access continuous renal replacement therapy (CRRT). Which nursing intervention should the nurse add to the patients plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor the access site for leaking or hemorrhage.

2. Check settings on the external pump every 2 hours.

3. Monitor pulses in distal extremities.

4. Monitor for hemodynamic instability from rapid removal of water and wastes from the blood.

5. Monitor the tube for clotting.

Correct Answer: 1,3

Rationale 1: Arteriovenous CRRT requires cannulation of an artery, so hemorrhage is a risk for which the nurse should monitor.

Rationale 2: Arteriovenous CRRT does not require use of an external pump.

Rationale 3: Arteriovenous CRRT increases risk of limb ischemia, so the nurse must monitor for distal pulses regularly.

Rationale 4: Hemodynamic instability from rapid removal of water and wastes is an adverse effect of intermittent dialysis. Continuous dialysis does not have this same adverse effect. Hemodynamic instability in continuous dialysis is more likely related to hemorrhage.

Rationale 5: Tube clotting is more associated with venovenous CRRT.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26-4

Question 10

Type: MCSA

A patient is receiving slow continuous ultrafiltration to treat an acute kidney injury. Which nursing assessment will this treatment specifically require?

1. Electrolyte levels

2. White blood cell count

3. Appetite

4. Urine output

Correct Answer: 1

Rationale 1: Slow continuous ultrafiltration is a method of continuous renal replacement that uses both arterial and venous access and, using the patients blood pressure, circulates blood through the hemofilter. The goal of this therapy is to remove fluid only, and the patient does not receive any replacement fluid. Toxins are not removed with this treatment and urea levels and electrolytes are not corrected. The nurse will need to continue to assess this patients electrolyte levels.

Rationale 2: The white blood count is monitored for development of infection in all patients. This level is not the most specific assessment necessary for this patient.

Rationale 3: Appetite assessment is necessary for all patients who are able to eat. This assessment is not specifically indicated for this patient.

Rationale 4: The patient is experiencing acute renal failure and may or may not have a urine output. Introduction of this technique to filter the blood will not change whether output is or is not present.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-4

Question 11

Type: MCSA

A patient in the intensive care unit is receiving continuous venovenous hemofiltration for acute kidney injury. In order for the nurse to successfully provide the treatment for the patient, what needs to occur?

1. Infusion of a dialysate through the hemofilter

2. Creation of a fistula

3. Connection to a small pump

4. Successful placement of the catheter in an artery and a vein

Correct Answer: 3

Rationale 1: Continuous venovenous hemofiltration uses a pressure gradient rather than a concentration gradient (dialysate).

Rationale 2: A fistula is needed when the patient will be on long-term hemodialysis.

Rationale 3: Without the arterial pressure to drive the system, a small pump propels the blood from one lumen of the catheter through the hemofilter and back into the vein through the second lumen. The pump controls the blood flow and therefore the fluid removal rate.

Rationale 4: Continuous venovenous hemofiltration uses a double-lumen catheter placed in a vein. This eliminates the need for an arterial catheter and the associated risks of this device.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-4

Question 12

Type: MCSA

A patient with an acute kidney injury is experiencing fluid volume overload. When administering furosemide (Lasix) therapy to this patient, the nurse should set the continuous infusion device in which manner?

1. According to a calculation based upon the patients weight

2. According to a calculation based upon the patients potassium and sodium levels

3. At no more than 20 mg/minute

4. At a rate of 4 mg/minute

Correct Answer: 4

Rationale 1: Furosemide dosage is not calculated according to the patients weight.

Rationale 2: Furosemide dosage is not calculated according to the potassium and sodium levels.

Rationale 3: Intravenous push furosemide is given at a rate of 20 mg or less over 1 to 2 minutes.

Rationale 4: The nurse should set the continuous infusion to provide 4 mg of the medication per minute.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-3

Question 13

Type: MCSA

A patient with acute kidney injury is receiving renal replacement therapy. Which assessment finding would the nurse evaluate as best indicating this therapy is having its desired effects?

1. The patient had a soft formed stool this morning.

2. The patients lung sounds have improved.

3. The patient slept for 2 hours without awakening.

4. The patients serum protein level is normal.

Correct Answer: 2

Rationale 1: Soft formed stools are outcome criteria for the nursing diagnosis of altered nutrition.

Rationale 2: In fluid volume overload, the patient will demonstrate signs of pulmonary edema, peripheral edema, and increased weight. Evidence of successful treatment would be improved lung sounds, reduction in peripheral edema, and stabilization of weight towards normal.

Rationale 3: Improved quality of sleep is not an outcome measure for CRRT.

Rationale 4: A normal serum protein level would be outcome criteria for the nursing diagnosis of altered nutrition.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 26-5

Question 14

Type: MCMA

A patient diagnosed with kidney injury is on fluid restriction. Which nursing interventions should the nurse add to the patients plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Provide all fluid in the form of ice chips.

2. Provide frequent oral care.

3. Allow the patient to decide when the fluid will be ingested.

4. Provide fluids only when the patient complains of thirst.

5. Consider the amount of fluids that can be provided over a shift.

Correct Answer: 2,5

Rationale 1: Using small amounts of ice chips or frozen popsicles can provide comfort with less volume, but there is no indication that all fluids should be in this form.

Rationale 2: Oral care is an extremely important intervention to minimize oral mucosal damage and to increase patient comfort.

Rationale 3: The nurse should not let the patient decide when the fluid will be ingested since there might not be available fluid for medications and treatments.

Rationale 4: Fluids must be provided for medication administration, so providing fluids only when the patient complains of thirst is not a logical intervention.

Rationale 5: The nurse must consider individual patient variants such as treatments and medication administration to determine how to divide the available free water over a 24-hour period.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26-5

Question 15

Type: MCMA

A patient with an acute kidney injury is identified as being at risk for infection. Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Turn and reposition when necessary.

2. Avoid manipulation of venous access devices.

3. Post signs to remind visitors and staff to wash their hands.

4. Limit the use of antibiotic therapy.

5. Remove invasive devices as soon as medically possible.

Correct Answer: 3,5

Rationale 1: The patient should be turned and repositioned every 2 hours to prevent the pooling of secretions in the lungs and reduce the likelihood of pressure ulcer development.

Rationale 2: Vascular access devices should receive routine care according to agency policies.

Rationale 3: Frequent scrupulous hand washing is necessary to protect this patient. Hand washing is necessary for both staff and visitors.

Rationale 4: Antibiotic therapy is indicated in the patient with an acute kidney injury; however, the dosage will need adjustment according to the patients renal clearance rate.

Rationale 5: The nurse should attend to orders for removal of invasive devices as soon as possible.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-5

Question 16

Type: MCSA

The nurse is assessing the neurological status of a patient with chronic renal failure. Which finding would the nurse attribute to chronic renal failure?

1. Numbness and pain of the lower extremities

2. Expressive aphasia

3. Flaccid paralysis on the left side

4. Weak hand grasps

Correct Answer: 1

Rationale 1: Neurological symptoms are nonspecific and progressive in the patient with CRF. These symptoms include: sleep disorders, memory loss, impaired judgment, muscle cramps, and twitching. These may progress to asterixis, seizures, and coma. Peripheral neuropathy is also a component of chronic renal failure and is evidenced by numbness, tingling, or pain, especially in the lower extremities.

Rationale 2: The development of expressive aphasia is not normal in a patient with chronic renal failure and should be further evaluated.

Rationale 3: Flaccid paralysis is not normal in a patient with chronic renal failure and should be further evaluated.

Rationale 4: The development of weak hand grasps is not normal in a patient with chronic renal failure and should the further evaluated.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-6

Question 17

Type: MCSA

A patient with chronic renal failure is diagnosed with anemia. The nurse anticipates providing which therapy for this patient?

1. Vitamin B12 injections

2. Routine whole blood transfusions

3. Recombinant erythropoietin supplementation

4. Protein restriction

Correct Answer: 3

Rationale 1: Vitamin B12 injections would not help treat the anemia associated with renal failure.

Rationale 2: Routine whole blood transfusions are not indicated for this patient.

Rationale 3: The anemia of chronic renal failure is treated with recombinant human erythropoietin and iron supplementation.

Rationale 4: Protein restriction may be necessary for this patient, but it is not done to treat anemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26-6

Question 18

Type: MCSA

A patient with chronic renal failure and a blood pressure of 158/98 mm Hg refuses to take medication for the blood pressure. What information should the nurse provide for this patient?

1. One of the problems associated with high blood pressure in people with renal failure is the development of heart failure.

2. Some people with chronic renal failure and high blood pressure end up with an infection around their heart.

3. You must realize that untreated hypertension may cause you to develop pneumonia.

4. There is a significant increase in risk for anemia if hypertension is not treated.

Correct Answer: 1

Rationale 1: Hypertension, commonly seen in chronic renal failure, can progress to heart failure if left untreated.

Rationale 2: Pericarditis is a complication of end-stage renal disease, but it is inflammatory and not infectious.

Rationale 3: Pneumonia is not a potential problem because of untreated hypertension.

Rationale 4: The patient with chronic renal failure is at high risk for anemia, but this complication is not due to the presence of untreated hypertension.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-6

Question 19

Type: MCMA

The nurse is assessing the integumentary system of a patient with chronic renal failure. Which findings would the nurse associate with this disease history?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Flushed, ruddy color

2. Yellow-brown hue

3. Areas of excoriation

4. Moist, clammy skin

5. Rubbery consistency

Correct Answer: 2,3

Rationale 1: Pale skin is associated with chronic renal failure due to anemia.

Rationale 2: The yellow-brown coloring associated with chronic renal failure is related to uremia.

Rationale 3: The patient with chronic kidney failure often experiences pruritus associated with the presence of urea in the skin. This causes itching and the resultant scratching causes skin breaks and excoriation.

Rationale 4: Skin is typically dry and maybe flaky.

Rationale 5: There is no effect that changes the skin to a rubbery consistency.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-6

Question 20

Type: MCSA

A patients potassium level is 6.5 mEq/L. The nurse would prepare for which intervention?

1. Administration of intravenous fluids supplemented with 40 mEq of potassium in each liter of fluid

2. Administration of oral potassium 2 or 3 times daily until levels are normal

3. Administration of Kayexalate by rectum

4. Administration of a D50W bolus

Correct Answer: 3

Rationale 1: This patient does not require additional intravenous potassium.

Rationale 2: This patient does not require administration of oral potassium.

Rationale 3: Kayexalate is a sodium polystyrene sulfonate used to bind to and eliminate excess potassium. It is given orally or by enema. Since this patients potassium level is elevated, this intervention is indicated.

Rationale 4: D50W is not given to reduce potassium.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26-3

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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