FINAL EXAM PRACTICE

A nurse is planning for client who will undergo peritoneal dialysis. Which of the following
actions should the nurse (Select all apply)?

Monitor serum glucose levels

Report cloudy dialysate return

Assess for shortness of breath

Check the access site dressing for wetness

A nurse is caring for client who is taking sucralfate. Which of the following outcomes indicates a
therapeutic effect of the medications?

Relief of gastrointestinal pain

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic
kidney disease. The nurse should expect which of the following findings?

BUN 35 mg/dL and creatinine 4.9 mg/dL

A patient with bladder cancer undergoes cystectomy with formation ileal conduit. What
intervention would the nurse plan to do post-op day one?

Empty the drainage bag every 2-3 hours and measure the urinary output

A nurse is caring for an older adult client who has dementia and begins to have frequent episodes
of incontinence. Which of the following interventions would the nurse initiate to manage this
behavior?

Take the client to the bathroom every 2hrs

A nurse is teaching a client who will have an x-ray of the kidneys, ureters and bladder. Which of
the following statements should the nurse include in the teaching?

The procedure determines whether you have a kidney stone

A nurse is caring for client who has a left renal calculus and an indwelling urinary catheter.
Which of following assessment findings is the priority for the nurse to report to the provider?

absent urine output for 1 hour

A patient with continuous bladder irrigation following prostatectomy tells the nurse that he has
bladder spasms and leaking around the catheter. What action would the nurse take first?

Assess the patency around the catheter

A patient diagnosed with chronic Hepatitis B asks about drug therapy to treat the disease. What
is the most appropriate response by the nurse?

The medication interferon decreases the viral load and help prevent complications

Of following characteristics, identify those that are most common associated with cholelithiasis.
Select all that apply

Obesity

Age over 40

Multiparous female

Family history of gallbladder disease

Use of estrogen or oral contraceptives

A nurse preparing to initiate hemodialysis for a client who has acute kidney injury. Which of the
following actions should the nurse take? Select all that apply

Review the medications the client currently takes

Assess the AV fistula for a bruit

Measure the client’s weight

Check serum electrolytes

A nurse is caring for a client who has a urinary tract infection (UTI), Which of the following is
the priority invention by the nurse?
Administer an antibiotic

A nurse is caring for client who has chronic renal disease and receiving therapy with epoetin
alfa. Which of the following laboratory results should the nurse review for an indication of a
therapeutic effect of the medication

The hematocrit (HcT)

Following electrohydraulic lithotripsy for treatment renal calculi, what is the most appropriate
nursing intervention for a patient?

Encourage fluid intake of 3 L/day

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the
client for which of the following manifestations of peritonitis?

Nausea and vomiting

While caring for the patient in the oliguric phase of acute kidney injury (AKI), the nurse
monitors the patient for associated collaborative problems. When would the nurse notify the
HCP?

The patient experiences increasing muscle weakness and abdominal cramping

A nurse is completing the admission assessment of a client who acute pancreatitis. Which of the
following findings is the priority to report?

Hand spasms present when blood pressure is checked

A nurse is planning care for a client who has chronic pyelonephritis. Which of the following
actions should the nurse plan to take (Select all that apply)

Palpate the costovertebral angle

Monitor urinary output

Administer antibiotics

Aminophylline is infusing at 30 ml/hr. The drug is mixed 250 mg in 500 ml DSW. How many
mg/hr is patient receiving?
15mg/hr

The physician writes an order for heparin 900 units/hr. The label on the I.V. bag reads: Heparin
10,000 units in 500 ml DSW. How many ml/hr will deliver the correct dose?

45 ml/hr

A nurse is providing discharge teaching to a client who is postoperative following open

cholecystectomy with T-tube placement. Which of the following instructions should the nurse
include in the teaching (Select all that apply)

Clamp T-tube for 1 hr before and after meal

Keep the drainage system above the level of the abdomen

List in the order you will perform a clean catch urine collection from a male patient

1. Open specimen container; do not touch the inside of the cup or the cover.

2. Open towelette.

3.Retract foreskin (if present) and use the towelette to clean the entire head of the penis.

4 Begin urinating into the toilet and bring the container into the stream to collect a clean, mid-
stream specimen.

5 Finish urination into the toilet.

6. Secure the cover.

A nurse is caring for client 4 hr postoperative following a kidney biopsy. Which of the following
interventions should the nurse take (Select all that apply)

Monitor for hematuria

Administer aspirin PRN pain

Check for urine for leukocyte esterase and nitrites

Monitor for extravasation of tissue surrounding the biopsy site

A nurse is assessing the clients in a health clinic for risk factors for contracting hepatitis. Which
of the following clients is at risk for developing hepatitis C?

A client who has multiple tattoos

A nurse is planning for a client who Stage 4 chronic kidney disease. Which of the following
actions should the nurse include in the plan of care? Select all that apply

Assess for jugular vein distention.

Provide frequent mouth rinses.

Auscultate for a pleural friction rub

Monitor for dysrhythmias

A nurse is planning post procedure care for a client who received hemodialysis. Which of the
following interventions should the nurse include in the plan of care? Select all that apply

Check BUN and serum creatinine.

Administer medications the nurse withheld prior to dialysis.
Observe for signs of hypovolemia.
Assess the access site for bleeding

A nurse is reviewing the medication record for client who has chronic kidney disease. Which of
the following medications should the nurse identify as having the potential to cause
nephrotoxicity?

Vancomycin

A patient with a gunshot wound to the abdomen complains of increasing abdominal pain several
hours after surgery to repair the bowel. What action would the nurse take first?

Take the patient's vital signs

The patient taking nitrofurantoin (Macrodantin) for urinary tract infection and tells the nurse has
turned dark. Which statement is the nurse’s best response?

This is a side effect of the medication and is not harmful.

What is the most challenging nursing interventions to promote healing in the patient with viral
hepatitis?

providing adequate nutritional intake

A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in
potassium. Which of the following foods should the nurse instruct the client to avoid? Select all
that apply

Tomatoes

Bananas

Avocado

A nurse is monitoring a client who had a kidney biopsy for postoperative complications. Which
of the following complication should the nurse identify as causing the greatest risk to the client?

Hemorraghe

A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a marked
distended bladder. Which intervention prescribed by the health care provider should nurse
implement first?

Insert a urinary retention catheter.

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the
nurse’s teaching about management of CKD has been effective?

I will measure my urinary output each day to help calculate the amount I can drink

A nurse is reviewing the results of client’s urinalysis. The findings indicate the urine is positive
for leukoctye esterase and nitrites. Which of the following actions should the nurse take?

Obtain a clean-catch urine specimen for culture and sensitivity

When working with patients with urologic problems, which interventions would be delegated to
an unlicensed assistive personnel (UAP)? Select all apply
assist incontinent patient to commode at regular intervals
provide perineal care with soap and water around a urinary catheter

What can patients at risk for nephrolithiasis do to prevent stones?

Drink enough fluids to produce dilute urine

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the
following findings should the nurse expect?

Epigastric pain radiating to the left shoulder

A client who is scheduled for kidney transplantation surgery is assessed by the nurse for the risk
factors of surgery. Which of the following findings increase the client’s risk of surgery? Select
all that apply

Age > 70 years

BMI 41
administering NPH each morning
past hx of lymphoma

A nurse is assessing a client who has a urine output of 250 ml in 24-hr period. Which of the
following descriptive terms should the nurse place in the client’s electronic record?

Oliguria

A nurse is caring for several clients. Which of the following clients are risk for developing
pyelonephritis? Select all that apply

Client who is 32 weeks of gestation

A client who has kidney calculi

A client who has a neurogenic bladder

A client who has diabetes mellitus

A nurse is assessing a client who has end-stage kidney disease. Which of the following findings
should the nurse expect? Select all that apply

Anuria
Marked azotemia
Crackles in the lungs

Proteinuria

A nurse is teaching a client who has chronic kidney disease and is to begin hemodialysis. Which
of the following information should the nurse include in the teaching?

Hemodialysis returns a balance to serum electrolytes

What treatment measure is used in the management of the patient with acute pancreatitis?

Nasogastric (NG) suction to prevent gastric contents from entering the duodenum

A nurse is planning care for a client who has postrenal AKI due to metastatic cancer. The client
has a serum creatinine of 5 mg/dL. Which of the following interventions should the nurse include
in the plan? Select all apply

Provide a high‐protein diet.

Assess the urine for blood.
Monitor for intermittent anuria.

A nurse is reviewing a new prescription for ursodiol with a client who cholelithiasis. Which of
the following information should the nurse include in the teaching?

This medication dissolves gallstones gradually over a period of up to 2 years

A nurse is planning care for client who is scheduled to have a kidney biopsy. Which of the
following information should the nurse include in the plan? Select all that apply

Maintain NPO status prior to the procedure

Obtain written, informed consent

Obtain coagulation studies

Administer (Benedryl) prior to procedure

The nurse is preparing the patient for the placement of an indwelling urinary catheter. Which
statement has the priority for the nurse to ask the patient?
 Are you allergic to Iodine of Betadine?

You are caring for patient who admitted with cirrhosis. For the nursing diagnosis of Excess
Fluid Volume, which indicator is the most reliable for tracking fluid retention?

Performing daily weights with the same amount of clothing

 Question 1

A client has a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the
nurse would anticipate which of the following types of disability?

Paraplegia

 Question 2

A client is scheduled for a cerebral angiogram to assess recent symptoms of muscle weakness
and tingling in the extremities. What information would the nurse include in the
preprocedural teaching plan? Select all that apply.
A contrast dye may be given before test
Throat irritation and facial flushing may occur
It is necessary to report any known allergies to iodine or seafood prior to the procedure

 Question 3

A client with a cervical SCI is in a skeletal traction with a halo fixation device. Which of the
following actions can the nurse delegate to an LPN/LVN? Select all that apply.
Check skin for pressure injury,
 observe the halo sites for infection,
clean with peroxide.

 Question 4

A client with a spinal cord injury at the cervical level is identified. What intervention will be
done to facilitate respirations?

Performing a jaw-thrust maneuver

 Question 5

A nurse assess a client with suspected bacterial meningitis. Which documented finding of
meningeal irritation suggests this diagnosis? Select all that apply.
Nuchal rigidity,
positive Brudzinski’s
and Kernig’s sign,
photophobia

 Question 6

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous
hemianopsia when eating. Which of the following actions should the nurse take?
Remind the client to look for food on the left side of tray.

 Question 7

A nurse is assessing a client who has Parkinson's disease. Which of the following
manifestations should the nurse expect? Select all that apply.
Pill rolling,
 shuffling gait,
drooling,
lack of facial expression.

 Question 8

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of

the following actions would the nurse take to assess cranial nerve III?
Check the pupillary response to light

 Question 9

A nurse is assessing a client's extraocular eye movement as part of evaluating neurological

function. Which cranial nerve would be documented. Select all that apply.
3-Oculomotor, 4-Trochlear, 6-Abducens

 Question 10

A nurse is caring for a client 4 hrs following evacuation of a subdural hematoma. Which of
the following assessments is the nurse's priority?
Oxygen saturation

 Question 11

A nurse is caring for a client who had a left hemispheric cerebrovascular accident (CVA) 3
weeks ago. Which of the following goals would the nurse include in the client's rehabilitation
program?
Establish ability to communicate effectively

 Question 12
 A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm
precautions. Which of the following interventions would the nurse take?
Minimize environmental stimuli

 Question 13

A nurse is caring for a client who has impairment of cranial nerves IX and X. Which of the
following actions would the nurse take?
Keep suction at bedside

 Question 14

A nurse is caring for a client who has suspected Meniere's disease. Which of the following is
an expected finding?
Unilateral hearing loss

 Question 15

A nurse is caring for a client who is post-procedure following lumbar puncture and reports a
throbbing headache when sitting upright. Which of the following actions should the nurse
take? (Select all that apply.)
Assist pt to supine position,
administer opioid medication,
encourage pt to increase fluid intake.

 Question 16
A nurse is caring for a client who is prescribed seizure precautions. Which of the following
interventions should the nurse include in the client's plan of care?
Obtain IV access
 Question 17

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of
the following nursing interventions is of highest priority?
Suction saliva from patients mouth

 Question 18

A nurse is caring for a client who who has had a stroke involving the right hemisphere.
Which of the following alterations in function should the nurse expect?
Inability to recognize family members.

 Question 19

A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss
of peripheral vision. The nurse should recognize this as a manifestation of which of the
following diseases?
Open angle glaucoma

 Question 20

A nurse is completing the initial admission assessment and history for a client. Which of the
following is the priority action for the nurse to take?
Document allergies

 Question 21

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure
disorder. Which of the following interventions would the nurse include? (Select all that
 apply.)
Suction,
bed rails,
IV access

 Question 22

A nurse is instructing a client's family members about feeding safety for a client who has
dysphagia following a stroke. Which of the following instructions would the nurse include?
Rest 30 mins before meals, place food on unaffected side, small bites, sit upright

 Question 23

A nurse is planning care for a client who had a traumatic brain injury and is emerging
restlessly from a coma. Which of the following interventions would the nurse include in the
plan?
Reduce stimuli

 Question 24

A nurse is presenting discharge instructions to a client who has a chronic neurologic

condition. The client reports symptoms of diplopia, fatigue, and sensory change. Which of the
following nursing statements are appropriate?
Implement a schedule to include period of rest

 Question 25

A nurse is providing discharge instructions on phenytoin to a client with tonic-clonic seizure

disorder. Which instructions would the nurse include? Select all that apply.
Monitor for skin rash,
 perform good oral hygiene,
receive periodic bloodwork,
report any problems with walking or coordination,
slurred speech or nausea.

 Question 26

A nurse is providing teaching for a client who has anew diagnosis of dry macular
degeneration. Which of the following instructions should the nurse include in the teaching?
Increase intake of deep yellow or orange vegetables,
increase dietary intake of carotenoids and antioxidants

 Question 27

A nurse is reviewing the health record of a client who has severe otitis media. Which of the
following are expected findings? Select all that apply.
Enlarged tonsils and adenoids,
frequent colds,
meclizine is prescribed to relieve vertigo

 Question 28

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing
increased intracranial pressure (ICP). Which of the following assessment findings by the
nurse supports this suspicion? Diplopia

 Question 29
A patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential
assessment for the nurse to complete is
Observing respiratory rate and effort
 Question 30

A patient with a head injury after a motorcycle crash arrives in the emergency department
(ED) complaining of shortness of breath and severe eye pain. Which action will the nurse
take first?
Check the patient’s O2 sat

 Question 31

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic
bladder. Which action will the nurse include in the plan of care?
Instruct the patient how to self-catheterize

 Question 32

During an admission health assessment, the nurse elicits a positive Kernig's sign from the
patient. Which diagnostic test procedure would the nurse anticipate the HCP ordering to
confirm a diagnosis?
Lumbar Puncture

 Question 33

During an assessment of the motor system, the nurse finds that the patient has a staggering
gait and an abnormal arm swing. What would the nurse use this information to do?
Protect the patient from injury caused by falls

 Question 34
 During assessment of a patient with spinal cord injury, the nurse determines that the patient
has a poor cough with diaphragmatic breathing. Based on these findings, what would would
be the nurses's first action?
Assess lung sounds and respiratory rate

 Question 35
Following a T2 spinal cord injury, the patient develops a paralytic ileus. While this condition
is present, what would the nurse anticipate that the patient will need?
Nasogastric suctioning

 Question 36

Following a generalized tonic-clonic seizure, the patient is tired and sleepy. What care would
the nurse provide? Allow the pt to sleep

 Question 37

Following a lumbar puncture, what would the nurse assess the patient for?
Headache

 Question 38

In providing care for patients with chronic, progressive neurologic disease, what is the major
goal of treatment that the nurse works toward?
Maximize neurologic functioning for as long as possible.

 Question 39
Nurses at the change-of shift are discussing a patient who had a stroke, who has progressive
increasing weakness and decreasing level of consciousness. Which patient problem do they
 determine has the highest priority?
Risk for aspiration related to inability to protect airway

 Question 40

Several clients have been hospitalized for diagnosis of neurologic problems. Which client
would the nurse assess first?
Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram

 Question 41

The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose
intravenous injections of corticosteroid medication. Which nursing intervention would be
implemented?
Monitor the client's serum blood glucose levels frequently.

 Question 42

The client diagnosed with multiple sclerosis is scheduled for a magnetic resonance imaging
(MRI) scan of the head. Which information would the nurse teach the client about the test?
The machine will be loud and the client must not move the head during the test.

 Question 43

The client diagnosed with septic meningitis is admitted to the unit. Which health-care
provider's order would have the highest priority?
administer an intravenous antibiotic

 Question 44
 The client with Parkinson's disease is being admitted with a fever and patchy infiltrates in the
lung fields on the chest-x-ray. Which clinical manifestations of PD would explain these
assessment data?
Difficulty swallowing and immobility.

 Question 45

The intensive care nurse is caring for the client who has had intracranial surgery. Which
interventions would the nurse implement? Select all that apply.
Assessing for DVT,
Monitoring I&O,
Perform passive ROM exercises

 Question 46

The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which
nursing task would not be assigned to the LPN?

 Question 47

The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient
about
triggers leading to facial discomfort.

 Question 48

The nurse determines that teaching about management of migraine headaches has been
effective when the patient says which of the following?
"I will lie down someplace dark and quiet when the headaches begin."
 Question 49

The nurse determines that teaching about the management of migraine headaches has been
effective when the patient says which of the following?
"I will lie down someplace dark and quiet when the headaches begin."

 Question 50

The nurse is caring for a client who has just returned after having a left carotid artery
angioplasty and stenting. Which assessment information is of most concern to the nurse?
The patient has difficulty speaking

 Question 51

The nurse is caring for a client with a hemorrhagic stroke. Which medication would the nurse
question administering?
Clopidogrel (Plavix), an antiplatelet.

 Question 52

The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture.
Which intervention would the nurse implement? Select all that apply.
Obtain an informed consent from the client or significant other.
Have the client empty the bladder prior to the procedure.
Place the client in a side-lying position with the back arched.
Explain to the client what to expect during the procedure.

 Question 53
 The nurse is preparing to administer medications to the following clients. Which medication
would the nurse question administering?

 Question 54

The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse's
instructions for this test include
asking the patient to stand 20 feet from the wall chart.

 Question 55

The nurse observes a client ambulating in the hospital hall when the client's arm and legs
suddenly jerk and the client falls to the floor. Which of the following would the nurse do
first?
assess the patient for a possible head injury.

 Question 56

The nurse performing an eye examination using PERRLA. The "A" stands for
accommodation. The nurse will document normal findings for accommodation when
the pupils constrict while fixating on an object being moved closer to the patient's eyes.

 Question 57

The nurse's initial action for a patient with moderate dementia who develops increased
restlessness and agitation should be to
assess for factors that might be causing discomfort.

 Question 58
 The nurse's initial action for a patient with moderate dementia who develops increased
restlessness and agitation should be to
assess for factors that might be causing discomfort

 Question 59

The occupational health nurse is caring for an employee who is complaining of bilateral eye
pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse
take?
Flush the eyes with sterile saline.

 Question 60

To decrease the risk for future hearing loss, which action should the nurse implement with
college students at the on-campus health clinic?
Discuss importance of limiting exposure to loud amplified music.

 Question 61
To determine whether treatment is effective for a patient with primary open-angle glaucoma
(POAG), the nurse can evaluate the patient for improvement by
visual field.

 Question 62

What would the nurse do to prepare a patient for a lumbar puncture?

Position the patient in a lateral recumbent position with the hips, knees, and neck flexed.

 Question 63
 When teaching patient with seizure disorder about the medication regime, what is most
important for the nurse to emphasize?
Stopping the medication abruptly may increase the intensity and frequency of seizures.

 Question 64

Which actions would you delegate to an experienced UAP who is caring for a client with a
stroke who has residual left-sided weakness? Select all that apply.
Assisting the client to reposition every 2 hours.
Reapplying pneumatic compression boots.
Reminding the client to perform active ROM exercises
Setting up meal trays and assisting with feeding

 Question 65

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's
most immediate action?
The patient is continuously drooling saliva.

 Question 66
Which assessment data indicate that the client with a traumatic brain injury (TBI) exhibiting
decorticate posturing on admission is responding effectively to treatment?
The client has purposeful movement

 Question 67
Which assessment finding alerts the nurse to provide patient teaching about cataract
development?

Blurred vision and light sensitivity

 Question 68

Which equipment will the nurse obtain to perform a Rinne test?

Tuning fork

 Question 69

Which intervention will the nurse include in the plan of care for a patient with moderate
dementia who had a fractured hip repair 2 days ago?
Remind the patient frequently about being in the hospital.

 Question 70

Which is a common cognitive problem associated with Parkinson's disease?

Memory deficits are cognitive impairment

 Question 71

Which neurologic diagnostic test has the highest risk of complications and requires frequent
monitoring of neurologic and vital signs after the procedure?
cerebral angiography

 Question 72
Which nursing action has the highest priority for a client who was admitted 16 hours earlier
with a C5 spinal cord injury?
Assessment of respiratory rate and effort
 Question 73

Which nursing action has the highest priority for a patient who was admitted 16 hours earlier
with a C5 spinal cord injury?
Assessment of respiratory rate and effort

 Question 74

Which of the following medications will be administered to a client with an acute SCI. Select
all that apply.

Positive inotropes
IV Fluids
Vasopressors

 Question 75

Which potential pituitary complication would the nurse assess for in a client diagnosed with a
traumatic brain injury (TBI)?
SIADH

 Question 76

Which prescribed intervention will the nurse implement first for a client in the emergency
department who is experiencing tonic-clonic seizures?
Administer lorazepam (Ativan) 4 mg IV.

 Question 77
 You are monitoring a client's intracranial pressure (ICP). How would you respond when the
physician ask for a report on the client's condition? ICP Flowsheet Recordings: 8:00 am – 20;
8:05 am – 18; 8:10 am – 18; 8:15 am - 16.
Within normal limit

 Question 78
You are the nurse manager on the floor. You have an new RN, an experienced RN, an LPN
and a UAP. Which client would you assign to a new RN who is on orientation to the
neurology unit?

 Question 79

A patient is being admitted with a possible stroke. Which information from the assessment
indicates that the nurse should consult with the health care provider before giving the
prescribed aspirin?
The patient reports that symptoms began with a severe headache

 Question 80

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture
was performed in the emergency department. Which action prescribed by the health care
provider should the nurse question?
Restrict oral fluids to 1000 mL daily.

A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following
statements by clients indicates an understanding of the teaching? Select all that apply
I plan to eat small, frequent meals

I will eat easy to digest foods with limited spice

I will use skim milk when cooking

A nurse is assessing a client who has an obstruction of the common bile duct resulting from
chronic cholecystitis. Which of the following findings would the nurse expect to see? Select all
that apply

Steatorrhea

Pruritus

Dark amber colored urine

A nurse is reviewing nutrition teaching for a client who has cholecystitis. The nurse should the
identify which of the following food choices can trigger cholecystitis?

Brownie with nuts

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of
the following provides a reliable measure of fluid retention?

Daily weight

The nurse is preparing to insert an 18 French indwelling urinary catheter in a client who has a
latex allergy. Which intervention is most important for the nurse to implement?

Use latex free gloves when performing this procedure

A nurse is reviewing discharge instructions with a client who had spontaneous passage of a
calcium phosphate renal calculus. Which of the following instructions should the nurse include
in the teaching (Select all that apply)

Limit intake of food high in animal protein.

Reduce sodium intake.

Report burning with urination to the provider.

Increase fluid intake to 3 L/day.
A nurse is reviewing client laboratory data. The nurse should recognize that which of the
following findings is expected for a client who has Stage 4 chronic kidney disease?

Glomerular ltration rate (GFR) 20 mL/min

A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the
following statements should the nurse make?

You should increase your daily intake of protein

A nurse is providing dietary teaching to a client who chronic kidney disease (CKD). The nurse
should instruct the client to limit which of the following nutrients? (Select all that apply)

Phosphorous

Sodium

A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic
cholecystectomy. Which of following should be included in the teaching?

You might have shoulder pain after surgery

A nurse is teaching a client who is scheduled for extracorporeal shock wave lithotripsy (ESWL)
Which of the following statements by the client indicates understanding of teaching?

Straining my urine following the procedure is important

Which menu choice by the patient who is receiving hemodialysis indicates that the nurse’s
teaching has been successful?

Poached eggs, whole-wheat toast, and apple juice

A nurse is preparing educational material to present to female client who has frequent urinary
tract infections? Which of the following information should the nurse include?

Avoid sitting in a wet bathing suit

Empty the bladder when there is an urge to void

Take a shower daily

To prevent the most common serious complication of peritoneal dialysis (PD), what is most
important for the nurse to do?

Use strict aseptic technique in the dialysis procedures.

You are the charge nurse. Which patient will assign to a nurse floated to your unit from surgical
intensive care unit (SICU)?

A patient who has just undergone surgery for renal stent placement

A nurse in a clinic is reviewing the laboratory reports of a client who has suspected
cholelithiasis. Which of the following is an expected finding?

Direct bilirubin 2.1 mg/dL

A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr.
Which of the following actions is the nurse priority?

Administer pain medication.