QUIZ #1 (TERM 2) MEDICAL – SURGICAL NURSING (NUR 155)

ANSWERS AND RATIONALES

1. The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of
about 1400 mL/day. What is the RN's priority concern?
A. Ask the client about his or her bowel movements.
B. Have the client complete a diet diary for the past 2 days.
C. Instruct the client to increase oral intake to 2 to 3 L/day.
D. Ask the client to describe his urine output.
Rationale: An adult should take in about 2 to 3 L of fluid daily from food and liquids. Although the RN would want to know about bowel movements,
dietary intake, and urine output, in this case, the priority is that the client is not taking in enough oral fluids. Focus: Prioritization.

2. The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by
the RN to unlicensed assistive personnel (UAP)?
A. Administering IV fluids as prescribed by the physician
B. Providing straws and offering fluids between meals
C. Developing a plan for added fluid intake over 24 hours
D. Teaching family members to assist the client with fluid intake
Rationale: UAPs can reinforce additional fluid intake when it is part of the care plan. Administering IV fluids, developing plans, and teaching families
require additional education and skills that are within the scope of practice of an RN.

3. The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine output for the past 24 hours has been only 360
mL. What is the nurse's priority action at this time?
A. Place an 18-gauge IV in the nondominant arm.
B. Elevate the client's head of bed at least 45 degrees.
C. Instruct the UAP to provide the client with a pitcher of ice water.
D. Contact and notify the health care provider immediately.
Rationale: The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the
obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte
imbalances, acidosis, and a toxic buildup of nitrogen. The client may need additional fluids (IV or oral) after the cause of the low urine output is
determined. Elevating the head of the bed will not help with urine output. Notifying the health care provider is the first priority in this case. Focus:
Prioritization.

4. The client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding
supports this risk?
A. Flattened neck veins when the client is in the supine position
B. Full and bounding pedal and post-tibial pulses
C. Pitting edema located in the feet, ankles, and calves
D. Shallow respirations with crackles on auscultation
Rationale: Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position.
The other three responses are characteristic of excess fluid volume. Focus: Prioritization.

5. The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the
scope of practice for an LPN/LVN being supervised by a nurse? Select all that apply.
A. Reminding the client to avoid commercial mouthwashes
B. Encouraging mouth rinsing with warm saline
C. Assess skin turgor by pinching the skin over the back of the hand
D. Observing the lips, tongue, and mucous membranes
E. Providing mouth care every 2 hours while the client is awake
F. Seeking a dietary consult to increase fluids on meal trays
Rationale: The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to
whether LPNs/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain agents
such as alcohol. To assess skin turgor in an older adult, skin tenting is best checked by pinching the skin over the sternum or on the forehead rather
than the back of the hand. With aging, the skin loses elasticity and tents on hands and arms even when the adult is well hydrated. Initiating a dietary
consult is within the purview of the RN or health care provider.

6. The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning
assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order
takes priority at this time?
A. Weigh the client every morning.
B. Maintain accurate intake and output records.
C. Restrict fluids to 1500 mL/day.
D. Administer furosemide 40 mg IV push.
Rationale: Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help
mobilize the fluid in the lungs. The other orders are important but are not urgent. Focus: Prioritization.

7. Which statement by a client with hypovolemia related to dehydration is the best indicator to the nurse of the need for additional
teaching?
A. “I will drink 2 to 3 L of fluids every day.”
B. “I will drink a glass of water whenever I feel thirsty.”
C. “I will drink coffee and cola drinks throughout the day.”
D. “I will avoid drinks containing alcohol.”
Rationale: Mild dehydration is very common among healthy adults and is corrected or prevented easily by matching fluid intake with fluid output.
Teach all adults to drink more fluids, especially water. Beverages with caffeine can increase fluid loss, as can drinks containing alcohol. These beverages
should not be used to prevent or treat dehydration. Focus: Prioritization.

8. The nurse has been floated to the telemetry unit for the day. The monitor technician informs the nurse that the client has
developed prominent U waves. Which laboratory value should be checked immediately?
A. Sodium
B. Potassium
C. Magnesium
D. Calcium
Rationale: Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression,
inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block. Other abnormal electrolyte levels can affect cardiac
rhythms, but the occurrence of U waves is associated with low potassium levels. Focus: Prioritization.

9. A client's potassium level is 6.7 mEq/L (6.7 mmol/L). Which intervention should the nurse delegate to the first-year student nurse
whom he or she is supervising?
A. Administer sodium polystyrene sulfonate 15 g orally.
B. Administer spironolactone 25 mg orally.
C. Assess the electrocardiogram (ECG) strip for tall T waves.
D. Administer potassium 10 mEq (10 mmol/L) orally.
Rationale: The client's potassium level is high (normal range is 3.5 to 5 mEq/L or 3.5 to 5 mmol/L). Sodium polystyrene sulfonate removes potassium
from the body through the gastrointestinal system. Spironolactone is a potassiumsparing diuretic that may cause the client's potassium level to go even
higher. A KCl supplement can also raise the potassium level even higher. The beginning nursing student does not have the skill to assess ECG strips.
Focus: Delegation, Supervision.

10. A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which
electrolyte abnormality would the nurse be sure to monitor?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypernatremia
Rationale: SIADH results in a relative sodium deficit caused by excessive retention of water. Focus: Prioritization.

11. The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions
can the new-graduate RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
A. Providing oral care every 3 to 4 hours
B. Monitoring for indications of dehydration
C. Administering 0.45% saline by IV line
D. Record urine output when client voids
E. Assessing daily weights for trends
F. Help the client change position every 2 hours
Rationale: Providing oral care, assisting clients to reposition, and recording urine output are within the scope of practice of the UAP. Monitoring and
assessing clients, as well as administering IV fluids, require the additional education and skills of the RN. Focus: Assignment, Delegation, Supervision.

12. An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was
assessed, one side twitches. What action should the RN take at this time?
A. Reassess the client's blood pressure and heart rate.
B. Review the client's morning calcium level.
C. Request a neurologic consult today.
D. Check the client's pupillary reaction to light.
Rationale: A positive Chvostek sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front
of the ear) is a neurologic manifestation of hypocalcemia. The heart rate may be slower or slightly faster than normal, with a weak, thready pulse.
Severe hypocalcemia causes severe hypotension. The LPN/LVN is experienced and possesses the skills to accurately measure vital signs. Focus:
Prioritization. 13. Ans: 4 Clients with low calcium levels should be encouraged to eat dairy products, seafood, nuts, broccoli, and spinach, which are all
good sources of dietary calcium. The other three options indicate correct understanding of calcium therapy. Focus: Prioritization.

13. The nurse is preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5
mg/dL [2.25 to 2.63 mmol/L]). Which statement by the client indicates the need for additional teaching?
A. “I will call my doctor if I experience muscle twitching or seizures.”
B. “I will make sure to take my vitamin D with my calcium each day.”
C. “I will take my calcium citrate pill every morning before breakfast.”
D. “I will avoid dairy products, broccoli, and spinach when I eat.”
Rationale: Clients with low calcium levels should be encouraged to eat dairy products, seafood, nuts, broccoli, and spinach, which are all good sources
of dietary calcium. The other three options indicate correct understanding of calcium therapy. Focus: Prioritization.

14. Which order prescribed for a client with hypercalcemia would the nurse be sure to question?
A. 0.9% saline at 50 mL/hr IV
B. Furosemide 20 mg orally each morning
C. Apply cardiac telemetry monitoring
D. Hydrochlorothiazide (HCTZ) 25 mg orally each morning
Rationale: Calcium excretion is decreased with thiazide diuretics (e.g., HCTZ), so the calcium level is at risk for going even higher. Loop diuretics (e.g.,
furosemide) increase calcium excretion. The addition of IV fluids and cardiac monitoring are appropriate actions for monitoring and treating a client with
hypercalcemia. Focus: Prioritization.

15. The unlicensed assistive personnel (UAP) asks the nurse why the client with a chronically low phosphorus level needs so much
assistance with activities of daily living. What is the RN's best response?
A. “The client's low phosphorus is probably due to malnutrition.”
B. “The client is just worn out from not getting enough rest.”
C. “The client's skeletal muscles are weak because of the low phosphorus.”
D. “The client will do more for himself when his phosphorus level is normal.”
Rationale: A musculoskeletal manifestation of low phosphorus levels is generalized muscle weakness, which may lead to acute muscle breakdown
(rhabdomyolysis). Phosphate is necessary for energy production in the form of adenosine triphosphate, and when not produced, leads to generalized
111 muscle weakness. Although the other statements are true, they do not answer the UAP's question. Focus: Delegation, Supervision.

16. The RN is reviewing the client's morning laboratory results. Which of these results is of most concern?
A. Serum potassium level of 5.2 mEq/L (5.2 mmol/L)
B. Serum sodium level of 134 mEq/L (134 mmol/L)
C. Serum calcium level of 10.6 mg/dL (2.65 mmol/L)
D. Serum magnesium level of 0.8 mEq/L (0.4 mmol/L)
Rationale: Although all of these laboratory values are outside of the normal range, the magnesium level is furthest from normal. With a magnesium
level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias. Focus: Prioritization.
17. Which client would the charge nurse assign to the step-down unit nurse who was floated to the intensive care unit for the day?
A. A 68-year-old client on a ventilator with acute respiratory failure and respiratory acidosis
B. A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator
dependent
C. A newly admitted 56-year-old client with diabetic ketoacidosis receiving an insulin drip
D. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis
Rationale: The client with COPD, although ventilator dependent, is in the most stable condition of the clients in this group and should be assigned to
the float nurse from the step-down unit. Clients with acid-base imbalances often require frequent laboratory assessment and changes in therapy to
correct their disorders. In addition, the client with diabetic ketoacidosis is a new admission and require an in-depth admission assessment. All three of
these clients need care from an experienced critical care nurse. Focus: Assignment.

18. The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results
indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this problem?
A. Increase in ventilator rate from 6 to 10 breaths/min
B. Decrease in ventilator rate from 10 to 6 breaths/min
C. Increase in oxygen concentration from 30% to 40%
D. Decrease in oxygen concentration from 40% to 30%
Rationale: The blood gas component responsible for respiratory acidosis is carbon dioxide, thus increasing the ventilator rate will blow off more carbon
dioxide and decrease or correct the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis. Focus:
Prioritization.

19. Which actions should the nurse delegate to an unlicensed assistive personnel (UAP) for the client with diabetic ketoacidosis?
Select all that apply.
A. Checking fingerstick glucose results every hour
B. Recording intake and output every hour
C. Measuring vital signs every 15 minutes
D. Assessing for indicators of fluid imbalance
E. Notifying the provider of changes in glucose level
F. Assisting the client to reposition every 2 hours
Rationale: The UAP's training and education includes how to measure vital signs, record intake and output, and reposition clients. Performing
fingerstick glucose checks and assessing clients requires additional education and skill, as possessed by licensed nurses. Notifying the provider of
glucose changes is within the scope of practice for licensed nurses. Some facilities may train experienced UAPs to perform fingerstick glucose checks
and change their role descriptions to designate their new skills, but this task is beyond the normal scope of practice of a UAP. Focus: Delegation,
Supervision.

20. The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this
client has a risk for acid base imbalances?
A. History of myocardial infarction (MI) 1 year ago
B. Antacid use for occasional indigestion
C. Shortness of breath with extreme exertion
D. Chronic renal insufficiency
Rationale: Risk factors for acid-base imbalances in older adults include chronic kidney disease and pulmonary disease. Occasional antacid use will not
cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis. The MI occurred 1 year ago and is no longer a risk factor. Focus:
Prioritization.

21. A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding
would the nurse instruct the student to report immediately?
A. Respiratory rate of 8 to 10 breaths/min
B. Decrease in pain level from 6 to 2 (on a scale of 1 to 10)
C. Request by the client that the room door be closed
D. Heart rate of 90 to 100 beats/min
Rationale: A decreased respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. All of the other
findings are important and should be reported to the RN, but the respiratory rate demands urgent attention. Focus: Delegation, Supervision.

22. The unlicensed assistive personnel (UAP) reports to the nurse that a client seems very anxious, and vital sign measurement
included a respiratory rate of 38 breaths/min. Which acid-base imbalance should the nurse suspect?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Rationale: The client is most likely hyperventilating and blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH and
cause respiratory alkalosis. Eliminating carbon dioxide would lead to an alkalosis. Metabolic imbalances would be related to renal changes. Focus:
Prioritization, Supervision.

23. A client is admitted to the oncology unit for chemotherapy. To prevent an acid-base problem, which finding would the nurse
instruct the unlicensed assistive personnel (UAP) to report?
A. Repeated episodes of nausea and vomiting
B. Reports of pain associated with exertion
C. Failure to eat all the food on the breakfast tray
D. Client hair loss during the morning bath
Rationale: Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to
be assessed but are not related to acid-base imbalances. Focus: Prioritization.

24. The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory
rate and depth has decreased. What is the nurse's best response?
A. “It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing.”
B. “The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory
mechanism.”
C. “Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem.”
D. “The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis.”
Rationale: Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client's decrease in rate and depth of
ventilation is an attempt to compensate by retaining carbon dioxide. The first response may be true, but it does not address all the components of the
question. The third and fourth answers are inaccurate. Focus: Supervision, Prioritization.
25. The client has an order for hydrochlorothiazide (HCTZ) 10 mg orally every day. What should the nurse be sure to include in a
teaching plan for this drug? Select all that apply.
A. “Take this medication in the morning.”
B. “This medication should be taken in two divided doses when you get up and when you go to bed.”
C. “Eat foods with extra sodium every day.”
D. “Inform your prescriber if you notice weight gain or increased swelling.”
E. “You should expect your urine output to increase.”
F. “Your health care provider may also prescribe a potassium supplement.”
Rationale: HCTZ is a thiazide diuretic. It should not be taken at night because it will cause the client to wake up to urinate. This type of diuretic causes
a loss of potassium, so the nurse should teach the client about eating foods rich in potassium and that the health care provider may prescribe a
potassium supplement. Weight gain and increased edema should not occur while the client is taking this drug, so these should be reported to the
prescriber. Focus: Prioritization.

26. Which blood test result would the nurse be sure to monitor for the client taking hydrochlorothiazide (HCTZ)?
A. Sodium level
B. Potassium level
C. Chloride level
D. Calcium level
Rationale: Potassium is lost when a client is taking HCTZ, and potassium level should be monitored regularly. Focus: Prioritization.

27. The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the
health care provider should the RN question?
A. Blood pressure every 15 minutes
B. Place two 18-gauge IV lines
C. Oxygen at 3 L via nasal cannula
D. IV 5% dextrose in water (D5W) to run at 250 mL/hr
Rationale: To correct hypovolemic shock with dehydration, the client needs IV fluids that are isotonic and will increase intravascular volume, such as
normal saline. With D5W, the body rapidly metabolizes the dextrose and the solution becomes hypotonic. All of the other interventions are appropriate
for a client with shock. Focus: Prioritization.

28. The student nurse, under the supervision of an RN, is reviewing a client's arterial blood gas results and notes an acute increase in
arterial partial pressure of carbon dioxide (Paco2) to 51 mm Hg compared with the previous results. Which statement by the student
nurse indicates accurate understanding of acid-base balance for this client?
A. “When the Paco2 is acutely elevated, the blood pH should be lower than normal.”
B. “This client should be taught to breathe and rebreathe in a paper bag.”
C. “An elevated Paco2 always means that a client has an acidosis.”
D. “When a client's Paco2 is increased, the respiratory rate should decrease to compensate.”
Rationale: This client's Paco2 is elevated (normal is 35 to 45 mm Hg). Whenever the Paco2 level changes acutely, the pH changes to the same degree,
in the opposite direction. As the amount of CO2 begins to rise above normal in brain blood and tissues, these central receptors trigger the neurons to
increase the rate and depth of breathing (hyperventilation). For these reasons, answers 2, 3, and 4 are inaccurate. Focus: Supervision, Prioritization.

29. The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is most at risk for respiratory
acidosis?
A. A 68-year-old client with chronic emphysema
B. A 58-year-old client who uses antacids every day
C. A 48-year-old client with an anxiety disorder
D. A 28-year-old client with salicylate intoxication
Rationale: Clients at greatest risk for acute acidosis are those with problems that impair breathing. Older adults with chronic health problems are at
greater risk for developing acidosis. Whereas a client who misuses antacids is at risk for metabolic alkalosis, a client with anxiety is at risk for respiratory
alkalosis. A client with salicylate intoxication is at risk for metabolic acidosis. Focus: Prioritization; Test Taking Tip: Respiratory acid-base disorders are
related to respiratory function. When a client has a chronic respiratory illness, he or she is at risk for a respiratory acid-base imbalance.

30. The nurse is caring for a client who experiences frequent generalized tonicclonic seizures associated with periods of apnea. The
nurse must be alert for which acid-base imbalance?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
Rationale: Seizures may be associated with apnea and thus hypoxemia and lactic acidosis. Lactic acidosis, a form of metabolic acidosis, occurs when
cells use glucose without adequate oxygen (anaerobic metabolism); glucose then is incompletely broken down and forms lactic acid. This acid releases
hydrogen ions, causing acidosis. Lactic acidosis occurs whenever the body has too little oxygen to meet metabolic oxygen demands (e.g., heavy
exercise, seizure activity, reduced oxygen). Focus: Prioritization.

31. The nurse is completing a history for an older client at risk for an acidosis imbalance. Which questions would the nurse be sure to
ask? Select all that apply.
A. “Which drugs to you take on a daily basis?”
B. “Do you have any problems with breathing?”
C. “When was your last bowel movement?”
D. “Have you experienced any activity intolerance or fatigue in the past 24 hours?”
E. “Over the past month have you had any dizziness or tinnitus?”
F. “Do you have episodes of drowsiness or decreased alertness?”
Rationale: Collect data about risk factors related to the development of acidosis. Older adults may be taking drugs that disrupt acid-base balance,
especially diuretics and aspirin. Ask about specific risk factors, such as any type of breathing problem. Also ask about headaches, behavior changes,
increased drowsiness, reduced alertness, reduced attention span, lethargy, anorexia, abdominal distention, nausea or vomiting, muscle weakness, and
increased fatigue. Ask the client to relate activities of the previous 24 hours to identify activity intolerance, behavior changes, and fatigue. Answers 3
and 5 are not common concerns with acidosis. Focus: Prioritization.

32. Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client
who is at risk for metabolic acidosis?
A. Check to see that the client keeps his oxygen in place at all times.
B. Inform the nurse immediately if the client's respiratory rate and depth increases.
C. Record any episodes of reflux or constipation.
D. Keep the client's ice water pitcher filled at all times.
Rationale: If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and
not under voluntary control, a pattern called Kussmaul respiration. The client may not require oxygen. Although it's important to record reflux and
constipation, this is not related to metabolic acidosis nor is keeping the water pitcher full specific to this condition. Focus: Supervision, Delegation.

33. A patient with a history of asthma presents to the emergency room with shortness of breath. Their ABG results are: pH 7.52,
PaCO2 30 mmHg, HCO3 24 mEq/L. What is the primary acid-base disturbance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Rationale: The pH is above the normal range (7.35-7.45), indicating alkalosis. The PaCO2 is below the normal range (35-45 mmHg), indicating that
the respiratory system is contributing to the alkalosis. The HCO3 is within the normal range (22-26 mEq/L), indicating that the metabolic system is not
involved.

34. A patient with diabetic ketoacidosis (DKA) is admitted to the ICU. Their ABG results are: pH 7.28, PaCO2 32 mmHg, HCO3 15
mEq/L. What is the primary acid-base disturbance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
E. Answer: c) Metabolic acidosis
Rationale: The pH is below the normal range (7.35-7.45), indicating acidosis. The PaCO2 is within the normal range (35-45 mmHg), indicating that the
respiratory system is not contributing to the acidosis. The HCO3 is below the normal range (22-26 mEq/L), indicating that the metabolic system is
involved. DKA is a classic example of metabolic acidosis.

35. A patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an exacerbation. Their ABG results
are: pH 7.34, PaCO2 58 mmHg, HCO3 30 mEq/L. What is the primary acid-base disturbance?
A. Uncompensated respiratory acidosis
B. Partially compensated respiratory acidosis
C. Fully compensated respiratory acidosis
D. Metabolic acidosis
Rationale: The pH is slightly below the normal range (7.35-7.45), indicating acidosis. The PaCO2 is above the normal range (35-45 mmHg), indicating
that the respiratory system is contributing to the acidosis. The HCO3 is above the normal range (22-26 mEq/L), indicating that the metabolic system is
attempting to compensate for the respiratory acidosis.

36. A patient with severe vomiting is admitted to the hospital. Their ABG results are: pH 7.55, PaCO2 40 mmHg, HCO3 32 mEq/L.
What is the primary acid-base disturbance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Rationale: The pH is above the normal range (7.35-7.45), indicating alkalosis. The PaCO2 is within the normal range (35-45 mmHg), indicating that
the respiratory system is not contributing to the alkalosis. The HCO3 is above the normal range (22-26 mEq/L), indicating that the metabolic system is
involved. Severe vomiting can lead to loss of stomach acid (HCl), resulting in metabolic alkalosis.

37. A patient with a history of chronic kidney disease (CKD) is admitted to the hospital with a respiratory infection. Their ABG results
are: pH 7.25, PaCO2 42 mmHg, HCO3 18 mEq/L. What is the primary acid-base disturbance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Rationale: The pH is below the normal range (7.35-7.45), indicating acidosis. The PaCO2 is within the normal range (35-45 mmHg), indicating that the
respiratory system is not contributing to the acidosis. The HCO3 is below the normal range (22-26 mEq/L), indicating that the metabolic system is
involved. CKD can lead to impaired kidney function, resulting in the inability to excrete acids, leading to metabolic acidosis.

38. A patient with a history of anxiety is brought to the emergency room after hyperventilating. Their ABG results are: pH 7.58, PaCO2
28 mmHg, HCO3 24 mEq/L. What is the primary acid-base disturbance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Rationale: The pH is above the normal range (7.35-7.45), indicating alkalosis. The PaCO2 is below the normal range (35-45 mmHg), indicating that
the respiratory system is contributing to the alkalosis. The HCO3 is within the normal range (22-26 mEq/L), indicating that the metabolic system is not
involved. Hyperventilation leads to a decrease in PaCO2, causing respiratory alkalosis.

39. A patient with severe sepsis is admitted to the ICU. Their ABG results are: pH 7.22, PaCO2 30 mmHg, HCO3 14 mEq/L. What is the
primary acid-base disturbance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Rationale: The pH is below the normal range (7.35-7.45), indicating acidosis. The PaCO2 is within the normal range (35-45 mmHg), indicating that the
respiratory system is not contributing to the acidosis. The HCO3 is below the normal range (22-26 mEq/L), indicating that the metabolic system is
involved. Sepsis can lead to lactic acidosis, a type of metabolic acidosis.

40. A patient with a history of alcohol abuse is admitted to the hospital with severe dehydration. Their ABG results are: pH 7.30,
PaCO2 48 mmHg, HCO3 26 mEq/L. What is the primary acid-base disturbance?
A. Uncompensated respiratory acidosis
B. Partially compensated respiratory acidosis
C. Fully compensated respiratory acidosis
D. Metabolic acidosis
Rationale: The pH is below the normal range (7.35-7.45), indicating acidosis. The PaCO2 is above the normal range (35-45 mmHg), indicating that the
respiratory system is contributing to the acidosis. The HCO3 is within the normal range (22-26 mEq/L), indicating that the metabolic system is not
attempting to compensate for the respiratory acidosis.

41. A patient with a history of chronic lung disease is admitted to the hospital with pneumonia. Their ABG results are: pH 7.38, PaCO2
52 mmHg, HCO3 28 mEq/L. What is the primary acid-base disturbance?
A. Uncompensated respiratory acidosis
B. Partially compensated respiratory acidosis
C. Fully compensated respiratory acidosis
D. Metabolic acidosis
Rationale: The pH is slightly below the normal range (7.35-7.45), indicating acidosis. The PaCO2 is above the normal range (35-45 mmHg), indicating
that the respiratory system is contributing to the acidosis. The HCO3 is above the normal range (22-26 mEq/L), indicating that the metabolic system is
attempting to compensate for the respiratory acidosis.

42. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PaCO2 of 30 mm Hg, and HCO3 of 20
mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?
A. Metabolic acidosis, compensated
B. Respiratory alkalosis, compensated
C. Metabolic alkalosis, uncompensated
D. Respiratory acidosis, uncompensated
Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PaCO2. In this situation,
the pH is at the high end of the normal value and the PCO2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the
question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to
a normal value, compensation has occurred.

43. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for
manifestations of which disorder that the client is at risk for?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the
accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the
loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric
suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.

44. A client with a 3-day history of nausea and vomiting and suspected gastroenteritis presents to the emergency department. The
client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays
tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn, and the nurse reviews the results, expecting to
note which
finding?
A. A decreased pH and an increased PaCO2
B. An increased pH and a decreased PaCO2
C. A decreased pHand a decreased HCO3
D. An increased pH and an increased HCO3
Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing
the pH and HCO3 to increase. Symptoms experienced by the client would include a decrease in the respiratory rate and depth, and tachycardia. Option
1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

45. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterrial blood gas (ABG) values are
pH = 7.53, PaO2 = 72 mm Hg, PaCO2 = 32 mm Hg, and HCO3 = 28 mEq/L (28 mmol/L). Which conclusion about the client would the
nurse make?
A. The client has acidotic blood.
B. The client is probably overreacting.
C. The client is uid volume overloaded.
D. The client is probably hyperventilating.
Rationale: The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis, not acidosis, as a result of
hyperventilating. Concluding that the client is overreacting is an inaccurate analysis. No conclusion can be made about a client’s fluid volume status from
the information provided.

46. The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations.
Which patterns did the nurse observe? Select all that apply.
A. Respirations that are shallow
B. Respirations that are increased in rate
C. Respirations that are abnormally slow
D. Respirations that are abnormally deep
E. Respirations that cease for several seconds
Rationale: Kussmaul’s respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In
bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.

47. A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following: pH is 7.12, PaCO2 is 90
mm Hg, and HCO3– is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?
A. Metabolic acidosis with compensation
B. Respiratory acidosis with compensation
C. Metabolic acidosis without compensation
D. Respiratory acidosis without compensation
Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mm
Hg. In respiratory acidosis the pH is decreased and the PCO2 is elevated. The normal bicarbonate HCO3– level is 21 to 28 mEq/L (21 to 28 mmol/L).
Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not
within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

48. The nurse notes that a client’s arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mm Hg. The nurse monitors
the client for which clinical manifestations associated with these ABG results? Select all that apply.
 A. Nausea
B. Confusion
C. Bradypnea
D. Tachycardia
E. Hyperkalemia
F. Light-headedness
Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation
of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the
respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, light-headedness, confusion, tachycardia, dysrhythmias related to
hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea
describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.

49. The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client
is experiencing respiratory acidosis. Which result validates the nurse’s findings?
A. pH 7.25, PaCO2 50 mm Hg
B. pH 7.35, PaCO2 40 mm Hg
C. pH 7.50, PaCO2 52 mm Hg
D. pH 7.52, PaCO2 28 mm Hg
Rationale: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a
part of the lungs. The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mm Hg.
In respiratory acidosis, the pH is decreased and the PaCO2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and
option 4 identifies respiratory alkalosis.

50. The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 50 and a PaCO2 of 30 mm Hg.
The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in
this condition?
A. Magnesium level of 1.8 (0.74 mmol/L)
B. Sodium level of 145 mEq/L (145 mmol/L)
C. Potassium level of 3.0 mEq/L (3.0 mmol/L)
D. Phosphorus level of 3.0 mg/dL (0.97 mmol/L)
Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation
of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the
respiratory system. Some clinical manifestations of respiratory alkalosis include light-headedness, confusion, tachycardia, dysrhythmias related to
hypokalemia, nausea, vomiting, diarrhea, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal
laboratory values. The correct option identifies the presence of hypokalemia.

51. The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?
A. Respiratory acidosis from inadequate ventilation
B. Respiratory alkalosis from anxiety and hyperventilation
C. Metabolic acidosis from calcium loss due to broken bones
D. Metabolic alkalosis from taking analgesics containing base product
Rationale: Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is
at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with
hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.
52. Aclient with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a
priority? Selectall that apply.
A. Place the client on a cardiac monitor.
B. Notify the health care provider (HCP).
C. Put the client on NPO (nothing by mouth) status except for ice chips.
D. Review the client’s medications to determine if any contain or retain potassium.
E. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.
Rationale: The normal potassium level is 3.5–5.0 mEq/L (3.5– 5.0 mmol/L). A potassium level of 7.0 is elevated. The client with hyperkalemia is at risk
of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. The nurse should notify the
HCP and also review medications to determine if any contain potassium or are potassium retaining. The client does not need to be put on NPO status.
Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Test-Taking Strategy:
Note the strategic word, priority. First, note that the potassium level is significantly elevated to select options 1 and 4.

53. A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and
anxious and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply.
A. Administer oxygen to the client.
B. Continue dialysis at a slower rate after checking the lines for air.
C. Notify the health care provider (HCP) and Rapid Response Team.
D. Stop dialysis, and turn the client on the left side with head lower than feet.
E. Bolus the client with 500 mL of normal saline to break up the air embolus.
Rationale: If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, position the client so the air
embolus is in the right side of the heart, notify the HCP and Rapid Response Team, and administer oxygen as needed. Slowing the dialysis treatment or
giving an intravenous bolus will not correct the air embolism or prevent complications.

54. A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The
nurse next assesses the client to determine a history of which condition?
A. Pyelonephritis
B. Glomerulonephritis
C. Trauma to the bladder or abdomen
D. Renal cancer in the client’s family
Rationale: Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and
pyelonephritis would be accompanied by fever and are thus not applicable to the client described in this question. Renal cancer would not cause pain
that is felt in the low abdomen; rather, the pain would be in the flank area.

55. The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment
should be included in this discussion? Select all that apply.
A. Hemodialysis
B. Peritoneal dialysis
 C. Kidney transplant
D. Bilateral nephrectomy
E. Intense immunosuppression therapy
Rationale: Polycystic kidney disease is a genetic familial disease in which the kidneys enlarge with cysts that rupture and scar the kidney, eventually
resulting in end-stage renal disease. Treatment options include hemodialysis or kidney transplant. Clients usually undergo bilateral nephrectomy to
remove the large, painful, cyst-filled kidneys. Peritoneal dialysis is not a treatment option due to the infected cysts. The condition does not respond to
immunosuppression.

56. A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes
insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take
which action?
A. Notify the HCP before performing the catheterization.
B. Use a small-sized catheter and an anesthetic gel as a lubricant.
C. Administer parenteral pain medication before inserting the catheter.
D. Clean the meatus with soap and water before opening the catheterization kit.
Rationale: The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the HCP, knowing that the client
should not be catheterized until the cause of the bleeding is determined by diagnostic testing. The other options include performing the catheterization
procedure and therefore are incorrect.

57. The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding
indicates that the fistula is patent?
A. Palpation of a thrill over the fistula
B. Presence of a radial pulse in the left wrist
C. Visualization of enlarged blood vessels at the fistula site
D. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand
Rationale: The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and
bruit indicate patency of the fistula. Enlarged visible blood vessels at the fistula site are a normal observation but are not indicative of fistula patency.
Although the presence of a radial pulse in the left wrist and capillary refill less than 3 seconds in the nail beds of the fingers on the left hand indicate
adequate circulation to the hand, they do not assess fistula patency.

58. A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder?
A. Hematuria and pyuria
B. Dysuria and proteinuria
C. Hematuria and urgency
D. Dysuria and penile discharge
Rationale: Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to
mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays.
Hematuria is not associated with urethritis. Proteinuria is associated with kidney dysfunction.

59. The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?
A. Fever, diarrhea, groin pain, and ecchymosis
B. Nausea, painful scrotal edema, and ecchymosis
C. Fever, nausea, vomiting, and painful scrotal edema
D. Diarrhea, groin pain, testicular torsion, and scrotal edema
Rationale: Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting,
and chills. Epididymitis most often is caused by infection, although sometimes it can be caused by trauma. The remaining options do not present all of
the accurate manifestations.

60. A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client’s problem is
related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder?
A. Soft and swollen prostate gland
B. Swollen, and boggy prostate gland
C. Tender and edematous prostate gland
D. Tender, indurated prostate gland that is warm to the touch
Rationale: The client with bacterial prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated. Systemic
symptoms include fever with chills, perineal and low back pain, and signs of urinary tract infection, which often accompany the disorder.

61. The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign
prostatic hyperplasia?
A. Nocturia
B. Scrotal edema
C. Occasional constipation
D. Decreased force in the stream of urine
Rationale: Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia. The stream later becomes weak and dribbling.
The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention
can occur. Constipation or scrotal edema is not associated with benign prostatic hyperplasia.

62. The nurse monitoring a client receiving peritoneal dialysis notes that the client’s outflow is less than the inflow. Which actions
should the nurse take? Select all that apply.
A. Check the level of the drainage bag.
B. Reposition the client to his or her side.
C. Contact the health care provider (HCP).
D. Place the client in good body alignment.
E. Check the peritoneal dialysis system for kinks.
F. Increase the flow rate of the peritoneal dialysis solution.
Rationale: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the side or
making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen
to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting and the clamps on the system
are checked to ensure that they are open. There is no reason to contact the HCP. Increasing the flow rate should not be done and also is not associated
with the amount of outflow solution.
63. A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations
of this complication?
A. Warmth, redness, and pain in the left hand
B. Ecchymosis and audible bruit over the fistula
C. Edema and reddish discoloration of the left arm
D. Pallor, diminished pulse, and pain in the left hand
Rationale: Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the
fistula. The client also complains of pain distal to the fistula, caused by tissue ischemia. Warmth and redness probably would characterize a problem
with infection. Ecchymosis and a bruit are normal findings for a fistula.

64. The nurse is reviewing a client’s record and notes that the health care provider has documented that the client has chronic renal
disease. On review of the laboratory results, the nurse most likely would expect to note which finding?
A. Elevated creatinine level
B. Decreased hemoglobin level
C. Decreased red blood cell count
D. Increased number of white blood cells in the urine
Rationale: The creatinine level is the most specific laboratory test to determine renal function. The creatinine level increases when at least 50% of
renal function is lost. A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with
decreased renal function. Increased white blood cells in the urine are noted with urinary tract infection.

65. A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse
notes that the client’s temperature is 38.5 °C (101.2 °F). Which nursing action is most appropriate?
A. Encourage fluid intake.
B. Notify the health care provider.
C. Continue to monitor vital signs.
D. Monitor the site of the shunt for infection.
Rationale: A temperature of 101.2 °F (38.5 °C) is significantly elevated and may indicate infection. The nurse should notify the health care provider
(HCP). Dialysis clients cannot have fluid intake encouraged. Vital signs and the shunt site should be monitored, but the HCP should be notified first.

66. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is
complaining of headache and nausea and is extremely restless. Which is the priority nursing action?
A. Monitor the client.
B. Elevate the head of the bed.
C. Assess the fistula site and dressing.
D. Notify the health care provider (HCP).
Rationale: Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral
edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome and appropriate
treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The HCP must be notified.
Monitoring the client, elevating the head of the bed, and assessing the fistula site are correct actions, but the priority action is to notify the HCP.

67. A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which
treatment will be done to relieve the obstruction? Select all that apply.
A. Peritoneal dialysis
B. Analysis of the urinary stone
C. Intravenous opioid analgesics
D. Insertion of a nephrostomy tube
E. Placement of a ureteral stent with ureteroscopy
Rationale: Urolithiasis is the condition that occurs when a stone forms in the urinary system. Hydronephrosis develops when the stone has blocked the
ureter and urine backs up and dilates and damages the kidney. Priority treatment is to allow the urine to drain and relieve the obstruction in the ureter.
This is accomplished by placement of a percutaneous nephrostomy tube to drain urine from the kidney and placement of a ureteral stent to keep the
ureter open. Peritoneal dialysis is not needed since the kidney is functioning. Stone analysis will be done later when the stone has been retrieved and
analyzed. Opioid analgesics are necessary for pain relief but do not treat the obstruction.

68. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to
maintain the prescribed dwell time for the dialysis because of the risk of which complication?
A. Peritonitis
B. Hyperglycemia
C. Hyperphosphatemia
D. Disequilibrium syndrome
Rationale: An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the
dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Peritonitis is a risk associated with breaks
in aseptic technique. Hyperphosphatemia is an electrolyte imbalance that occurs with renal dysfunction. Disequilibrium syndrome is a complication
associated with hemodialysis.

69. A week after kidney transplantation, a client develops a temperature of 101 °F (38.3 °C), the blood pressure is elevated, and there
is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the
transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment?
A. Antibiotic therapy
B. Peritoneal dialysis
C. Removal of the transplanted kidney
D. Increased immunosuppression therapy
Rationale: Acute rejection most often occurs within 1 week after transplantation but can occur any time posttransplantation. Clinical manifestations
include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function.
Treatment consists of increasing immunosuppressive therapy. Antibiotics are used to treat infection. Peritoneal dialysis cannot be used with a newly
transplanted kidney due to the recent surgery. Removal of the transplanted kidney is indicated with hyperacute rejection, which occurs within 48 hours
of the transplant surgery.

70. A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate
is performed. Four hours after surgery, the nurse takes the client’s vital signs and empties the urinary drainage bag. Which
assessment finding indicates the need to notify the health care provider (HCP)?
A. Red, bloody urine
 B. Pain rated as 2 on a 0–10 pain scale
C. Urinary output of 200 mL higher than intake
D. Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute
Rationale: Frank bleeding (arterial or venous) may occur during the first day after surgery. Some hematuria is usual for several days after surgery. A
urinary output of 200 mL more than 848 UNIT XIV Renal and Urinary Disorders of the Adult Client intake is adequate. Aclient pain rating of 2 on a 0–10
scale indicates adequate pain control. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The HCP should be notified.

71. The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for
disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations?
A. Hypertension, tachycardia, and fever
B. Hypotension, bradycardia, and hypothermia
C. Restlessness, irritability, and generalized weakness
D. Headache, deteriorating level of consciousness, and twitching
Rationale: Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching,
and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the
blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic
gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is
prevented by dialyzing for shorter times or at reduced blood flow rates. Tachycardia and fever are associated with infection. Generalized weakness is
associated with low blood pressure and anemia. Restlessness and irritability are not associated with disequilibrium syndrome.

72. A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign
prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?
A. Diuretics
B. Antibiotics
C. Antilipemics
D. Decongestants
Rationale: In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as
decongestants, anticholinergics, and antidepressants. These medications lessen the voluntary ability to contract the bladder. The client should be
questioned about the use of these medications if he has urinary retention. Diuretics increase urine output. Antibiotics and antlipemics do not affect
ability to urinate.

73. Nitrofurantoin is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills,
fever, and difficulty breathing. The nurse should make which interpretation about the client’s complaints?
A. The client may have contracted the flu.
B. The client is experiencing anaphylaxis.
C. The client is experiencing expected effects of the medication.
D. The client is experiencing a pulmonary reaction requiring cessation of the medication.
Rationale: Nitrofurantoin can induce 2 kinds of pulmonary reactions: acute and subacute. Acute reactions, which are most common, manifest with
dyspnea, chest pain, chills, fever, cough, and alveolar infiltrates. These symptoms resolve 2 to 4 days after discontinuing the medication. Acute
pulmonary responses are thought to be hypersensitivity reactions. Subacute reactions are rare and occur during prolonged treatment. Symptoms (e.g.,
dyspnea, cough, malaise) usually regress over weeks to months following nitrofurantoin withdrawal. However, in some clients, permanent lung damage
may occur. The remaining options are incorrect interpretations.

74. The nurse is providing discharge instructions to a client receiving trimethoprim-sulfamethoxazole. Which instruction should be
included in the list?
A. Advise that sunscreen is not needed.
B. Drink 8 to 10 glasses of water per day.
C. If the urine turns dark brown, call the health care provider (HCP) immediately.
D. Decrease the dosage when symptoms are improving to prevent an allergic response.
Rationale: Each dose of trimethoprim-sulfamethoxazole should be administered with a full glass of water, and the client should maintain a high fluid
intake to avoid crystalluria. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Clients
should be advised to use sunscreen since the skin becomes sensitive to the sun. Some forms of trimethoprimsulfamethoxazole cause urine to turn dark
brown or red. This does not indicate the need to notify the HCP.

75. Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it
develops during the course of this medication therapy?
A. Nausea
B. Diarrhea
C. Headache
D. Sore throat
Rationale: Clients taking trimethoprim-sulfamethoxazole should be informed about early signs and symptoms of blood disorders that can occur from
this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the health care provider (HCP) if these occur.
The other options do not require HCP notification.
76. Phenazopyridine is prescribed for a client with a urinary tract infection. The nurse evaluates that the medication is effective based
on which observation?
A. Urine is clear amber.
B. Urination is not painful.
C. Urge incontinence is not present.
D. A reddish-orange discoloration of the urine is present.
Rationale: Phenazopyridine is a urinary analgesic. It is effective when it eliminates pain and burning with urination. It does not eliminate the bacteria
causing the infection, so it would not make the urine clear amber. It does not treat urge incontinence. It will cause the client to have reddish-orange
discoloration of urine but this is a side effect of the medication, not the desired effect.

77. Bethanechol chloride is prescribed for a client with urinary retention. Which disorder would be a contraindication to the
administration of this medication?
A. Gastric atony
B. Urinary strictures
C. Neurogenic atony
D. Gastroesophageal reflux
Rationale: Bethanechol chloride can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the
ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could damage or
rupture the bladder in clients with these conditions.
78. The nurse, who is administering bethanechol chloride, is monitoring for cholinergic overdose associated with the medication. The
nurse should check the client for which sign of overdose?
A. Dry skin
B. Dry mouth
C. Bradycardia
D. Signs of dehydration
Rationale: Cholinergic overdose of bethanechol chloride produces manifestations of excessive muscarinic stimulation such as salivation, sweating,
involuntary urination and defecation, bradycardia, and severe hypotension. Remember that the sympathetic nervous system speeds the heart rate and
the cholinergic (parasympathetic) nervous system slows the heart rate. Treatment includes supportive measures and the administration of atropine
sulfate (anticholinergic) subcutaneously or intravenously.

79. Oxybutynin chloride is prescribed for a client with urge incontinence. Which sign would indicate a possible toxic effect related to
this medication?
A. Pallor
B. Drowsiness
C. Bradycardia
D. Restlessness
Rationale: Toxicity (overdosage) of oxybutynin produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and
irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression.
Drowsiness is a frequent side effect of the medication but does not indicate overdosage.

80. Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect
from the use of this medication?
A. Hemoglobin level of 14.0 g/dL (140 mmol/L)
B. Creatinine level of 0.6 mg/dL (53 mcmol/L)
C. Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L)
D. Fasting blood glucose level of 99 mg/dL (5.5 mmol/L)
Rationale: Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of cyclosporine. Nephrotoxicity is evaluated by monitoring for
elevated blood urea nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal
creatinine level for a male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and for a female 0.5 to1.1 mg/dL(44 to 97 mcmol/L). Cyclosporine can lower
complete blood cell count levels. A normal hemoglobin is Male: 14 to 18 g/dL (140 to 180 mmol/L); Female: 12 to 16 g/dL (120 to 160 mmol/L). A
normal hemoglobin is not an adverse effect. Cyclosporine does affect the glucose level. The normal fasting glucose is 70 to 110 mg/dL (4 to 6 mmol/L).
Test-Taking Strategy: Focus on the subject, the adverse effects of cyclosporine. Recall that cyclosporine can be nephrotoxic. The correct option is the
only one that indicates an increased level of a renal function test. Also, recalling the normal laboratory reference levels will direct you to the correct
option, the only abnormal level.

81. The nurse is providing dietary instructions to a client who has been prescribed cyclosporine. Which food item should the nurse
instruct the client to exclude from the diet?
A. Red meats
B. Orange juice
C. Grapefruit juice
D. Green, leafy vegetables
Rationale: A compound present in grapefruit juice inhibits metabolism of cyclosporine through the cytochrome P450 system. As a result, consumption
of grapefruit juice can raise cyclosporine levels by 50% to 100%, thereby greatly increasing the risk of toxicity. Red meats, orange juice, and green,
leafy vegetables do not interact with the cytochrome P450 system.

82. Tacrolimus is prescribed for a client who underwent a kidney transplant. Which instruction should the nurse include when
teaching the client about this medication?
A. Eat at frequent intervals to avoid hypoglycemia.
B. Take the medication with a full glass of grapefruit juice.
C. Change positions carefully due to risk of orthostatic hypotension.
D. Take the oral medication every 12 hours at the same times every day.
Rationale: Tacrolimus is a potent immunosuppressant used to prevent organ rejection in transplant clients. It is important that the medication be
taken at 12-hour intervals to maintain a stable blood level to prevent organ rejection. Adverse effects include hyperglycemia and hypertension, so the
client does not eat frequently to avoid hypoglycemia or use precautions to avoid orthostatic hypotension. Tacrolimus is metabolized through the
cytochrome P450 system, so grapefruit juice is not allowed.

83. The nurse is reviewing the laboratory results for a client receiving tacrolimus. Which laboratory result would indicate to the nurse
that the client is experiencing an adverse effect of the medication?
A. Potassium level of 3.8 mEq/L (3.8 mmol/L)
B. Platelet count of 300,000 mm3 (300 Â 109 /L)
C. Fasting blood glucose of 200 mg/dL (11.1 mmol/L)
D. White blood cell count of 6000 mm3 (5 to 10 Â 109 /L)
Rationale: A fasting blood glucose level of 200 mg/dL (11.1 mmol/L) is significantly elevated above the normal range of 70 to 110 mg/dL (4 to 6
mmol/L) and suggests an adverse effect. Recall that fasting blood glucose levels are sometimes based on health care provider preference. Other
adverse effects include neurotoxicity evidenced by headache, tremor, and insomnia; gastrointestinal effects such as diarrhea, nausea, and vomiting;
hypertension; and hyperkalemia. The remaining options identify normal reference levels. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0
mmol/L). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 Â 109 /L). The normal white blood cell count is 5000 to 10,000 mm3 (5 to
10 Â 109 /L).

84. The nurse receives a call from a client concerned about eliminating brown-colored urine after taking nitrofurantoin for a urinary
tract infection. The nurse should make which appropriate response?
A. “Continue taking the medication; the brown urine occurs and is not harmful.”
B. “Take magnesium hydroxide with your medication to lighten the urine color.”
C. “Discontinue taking the medication and make an appointment for a urine culture.”
D. “Decrease your medication to half the dose, because your urine is too concentrated.”
Rationale: Nitrofurantoin imparts a harmless brown color to the urine and the medication should not be discontinued until the prescribed dose is
completed. Magnesium hydroxide will not affect urine color. In addition, antacids should be avoided because they interfere with medication
effectiveness.
85. A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the
medication?
A. Hematocrit of 33% (0.33)
B. Platelet count of 400,000 mm3 (400 Â 109 /L)
C. White blood cell count of 6000 mm3 (6.0 Â 109 /L)
D. Blood urea nitrogen level of 15 mg/dL (5.25 mmol/L)
Rationale: Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to
treat anemia associated with chronic kidney disease. The normal hematocrit level is Male: 42% to 52% (0.42 to 0.52); Female: 37% to 47% (0.37 to
0.47). Therapeutic effect is seen when the hematocrit reaches between 30% and 33% (0.30 and 0.33). The normal platelet count is 150,000 to 400,000
mm3 (150 to 400 Â 109 /L). The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal white blood cell count is 5000 to
10,000 mm3 (5 to 10 Â 109 /L). Platelet production, white blood cell production, and blood urea nitrogen do not respond to erythropoietin