ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 68 Questions
Question 1 of 5
The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury. Which condition would the nurse expect to find in the client's recent history?
Correct Answer: B
Rationale: Myocardial infarction can lead to decreased cardiac output, reducing renal perfusion and causing pre-renal acute kidney injury. Myelonephritis and kidney stones are more associated with intrinsic or post-renal causes, respectively, while septic shock could also contribute but is less specific in this context.
Question 2 of 5
A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client's care?
Correct Answer: B
Rationale: The client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client's cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.
Question 3 of 5
A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the priority action?
Correct Answer: C
Rationale: The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion to prevent worsening of symptoms. Calculating MAP is important but not the priority when shortness of breath is evident. A pulmonary artery catheter is invasive and not the first action. Monitoring respiratory rate is important but secondary to adjusting the infusion.
Question 4 of 5
A client has a serum potassium level of 6.5 mEq/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL per 24 hours. What is the priority action by the nurse?
Correct Answer: A
Rationale: The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.
Question 5 of 5
A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse?
Correct Answer: D
Rationale: The central line should have a heparin or heparin/saline dwell after hemodialysis treatment to prevent clotting. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids.