Assessment 2 retake (1).docx Roseman University of Health Sciences NURSING BLOCK 10
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Course
NURSING bLOCK 10
Institution
NURSING BLOCK 10
1. The nurse is caring for a client who is receiving Peritoneal Dialysis (PD). What is the
priority nursing intervention during dialysis exchange?
a. Check blood glucose levels prior to dialysate instillation
b. Position the client only on the right side during instillation
c. Use sterile techn...
1. The nurse is caring for a client who is receiving Peritoneal Dialysis (PD). What is the
priority nursing intervention during dialysis exchange?
a. Check blood glucose levels prior to dialysate instillation
b. Position the client only on the right side during instillation
c. Use sterile technique when connecting dialysate bags
d. Make sure the fluid is refrigerated right before instillation
2. The nurse is caring for a client who has an arteriovenous (AV) fistula in the right upper
arm for hemodialysis treatments. What is the priority nursing action?
a. Take blood pressure on the right arm to ensure accuracy
b. Use the fistula for all laboratory draws and IV fluid infusions
c. Ensure small clamps are attached to the AV fistula dressing
d. Assess the fistula for the presence of bruits and thrills q4 hours
3. The nurse is performing peritoneal dialysis and notes cloudy dialysate in the fluid return
out of the abdomen. What is the nurses’ priority action?
a. Assess for edema in the lower extremities
b. Assess pulses distal to the catheter site
c. Send the dialysis solution to the laboratory
d. Check to see if the fluid is flowing freely
4. The nurse is caring for a client with chronic kidney disease (CKD) who is on low protein
diet. Which of the following laboratory result will the nurse report to the HCP
immediately?
a. Calcium level 9.5 mg/dL
b. Potassium level 4.9 mEq/L
c. Albumin level 1.5 g/dL
d. Magnesium level 2.0 mEq/L
5. The nurse is caring for a client who had hip surgery yesterday and has had 150 mLs of
urine output over the last 6 hours. What is the nurses’ priority action?
a. Place the patient on a pulse oximeter
b. Continue to measure urinary output once every shift
c. Bolus 500mL NS & assess for increased urinary output
d. Give spironolactone PO q4 hours to increase urine output
6. A client with intrarenal acute kidney injury (AKI) asks how to prevent further damage to
the kidneys. What is the nurses’ best response?
a. “You will need to undergo chemotherapy to prevent further damage”
b. “Damage to the glomerulus and nephrons will continue as you age”
c. “You should avoid taking NSAIDs, such as naproxen sodium (Aleve)”
d. “You will need to remain on clear liquids until you have hemodialysis”
, 7. The nurse is caring for a client who is admitted for NSAID overdose. The client has a BP
of 85/60 mmHg. What does the nurse expect to find upon assessment?
a. Urinary output of 90 mL in 6 hours
b. Heart rate of 80 bpm
c. BUN 18 mg/dL, Cr 0.7 mg/dL
d. Bilateral lower extremity pitting edema
8. A client has returned to the room following a CT scan with contrast dye. The nurse notes
the client now has decreased urine output and is lethargic. What laboratory value will the
nurse report to the HCP immediately?
a. Serum creatinine 1.6 mg/dL
b. BUN 20 mg/dL
c. Serum potassium 4.5 mEq/L
d. Serum sodium 145 mEq/L
9. The nurse is caring for a client with chronic kidney disease (CKD) and the clients
glomerular filtration rate (GFR) is now <14 mL/min. What is the priority nursing action?
a. Educate the client & family regarding hospice care
b. Educate the client about renal replacement therapy options
c. Teach client about an appropriate pain management plan
d. Start the client on additional hypertension medications
10. The nurse is assessing a client and notes they have a BP of 85/50 mmHg and they have
been vomiting blood for several days. What is the priority nursing action(s)? SATA
a. Administer NS bolus and repeat if necessary
b. Administer broad spectrum antibiotics within 1 hour
c. Start a vasopressor such as norepinephrine bitartrate
d. Type and cross the client for packed RBCs
e. ?
11. The nurse is assessing a client who was brought to the hospital by a family member. The
family reports the client has not had anything to eat or drink for several days and it took
three people to lift them in the car. The nurse notes the client is difficult to arouse and
they do not know what day it is or where they are. What additional assessment findings
will the nurse report to the HCP immediately?
a. Wheezes, SpO2 91% on RA, and no cyanosis noted
b. Client has iron deficiency anemia and a hemoglobin of 8.2 with pallor
c. Cap refill of 4 seconds, weak and thready pulses, HR of 132
d. A urinary output of 60 mLs/hour and RR of 22
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