Question

23. You are providing nursing care for a patient with acute kidney failure for whom a nursing diagnosis of Excess Fluid Volume related to compromised regulatory mechanisms has been identified. Which actions should you delegate to an experienced UAP? (Select all that apply.) a. Measuring and recording vital sign values every 4 hours b. Weighing the patient every morning using a standing scale c. Administering furosemide (Lasix) 40 mg orally twice a day d. Reminding the patient to save all urine for intake and output measurement e. Assessing breath sounds every 4 hours 1. Ensuring that the patient's urinal is within reach 24. You are caring for a patient admitted with dehydration secondary to deficient antidiuretic hormone (ADH). Which specific gravity value supports this diagnosis? a. 1.010 b. 1.035 c. 1.020 d. 1.002 25. A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? a. Infuse normal saline at 75 ml/hr. b. Obtain blood, urine, and sputum for cultures. c. Place the client on airborne and contact precautions. d. Give methylprednisolone (Solu-Medrol) 1 g IV. 26. The LPN is preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions? 1. Remove N95 respirator. 2. Take off goggles. 3. Remove gloves. 4. Take off gown. 5. Perform hand hygiene. a. b. c. d. e. 1, 2, 5, 4,3 5, 3, 2, 1,4 4,5, 1, 3, 2, 3, 2, 4, 1,5 2, 4, 5, 3,1 27. You are caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which nursing action can be delegated to an LPN/LVN? a. Planning ways to improve the client's oral protein intake b. Teaching the client about home care of the leg ulcer c. Obtaining wound cultures during dressing changes d. Assessing the risk for further skin breakdown

Answer 1

Q 23:A B,D and E

Decrease in output (to less than 400 ml per 24 hours) may indicate acute failure, especially in high-risk patients. Accurate monitoring of I&O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload. Do note that hypervolemia usually occurs in anuric phase of ARF and may mask the symptoms.

Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention.

Tachycardia and hypertension can occur because of: (1) failure of the kidneys to excrete urine, (2) excess fluid resuscitation during efforts to treat hypovolemia and/or hypotension or convert oliguric phase of renal failure, (3) changes in the renin-angiotensin system. Invasive monitoring may be needed for assessing intravascular volume, especially in patients with poor cardiac function.

Fluid overload may lead to pulmonary edema and HF evidenced by development of adventitious breath sounds, extra heart sounds

Question 24: A

Specific gravity measures the kidney's ability to concentrate or dilute urine in relation to plasma. Because urine is a solution of minerals, salts, and compounds dissolved in water, the specific gravity is greater than 1.000. The more concentrated the urine, the higher the urine specific gravity. An adult's kidneys have a remarkable ability to concentrate or dilute urine. In infants, the range for specific gravity is less because immature kidneys are not able to concentrate urine as effectively as mature kidneys.

Glucose, protein, or dyes used in diagnostic tests excreted into the urine increase the specific gravity. If none of these abnormal substances are present in the urine, there are two primary reasons why the kidney is producing concentrated urine with a high specific gravity. The first and most common reason for an increase in urine specific gravity is dehydration. The second reason for a high specific gravity is an increased secretion of anti-diuretic hormone (ADH). ADH causes increased tubular water re-absorption and decreased urine volume. Trauma, stress reactions, surgery, and many drugs cause an increase in ADH secretion.

thus the answer is A.

Question 25: D

Question 26: D

question 27: B/D