A nurse caring for a client who is at home on hospice care.

Exhibits

At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

Client calm not agitated. Grimaces with movement.

Oral mucous membranes dry.

Axillary temp 102 F (38.9 C), client shivering.

Productive cough.

Coarse rhonchi bilaterally. Crackles in bases.

Respirations irregular with periods of apnea

Client resting in recliner. RR 12, regular

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}

Client calm not agitated. Grimaces with movement.
No change: While the client is calm and not agitated, grimacing with movement indicates continued discomfort or pain, which remains unchanged.
Oral mucous membranes dry.

No change: Dry oral mucous membranes persist, suggesting ongoing dehydration or inadequate oral hydration.
Axillary temp 102 F (38.9 C), client shivering.

Declined: The axillary temperature has increased from 100.8 F (38.22 C) to 102 F (38.9 C), indicating a worsening of the client's fever. Shivering suggests the body's attempt to generate heat in response to the fever.
Productive cough.

No change: The client continues to have a productive cough, indicating ongoing respiratory congestion or infection.
Coarse rhonchi bilaterally. Crackles in bases.

Declined: The presence of coarse rhonchi bilaterally and crackles in the bases suggests worsening respiratory status, possibly indicating progression of underlying lung disease or development of complications such as pneumonia.
Respirations irregular with periods of apnea.

Improved: The client's respirations, previously irregular with periods of apnea, are now regular, indicating an improvement in respiratory function.
Client resting in recliner. RR 12, regular.

Improved: The client's respiratory rate has decreased from 18 to 12 breaths per minute, and respirations are now regular, suggesting improved respiratory status and possibly reduced distress.

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Correct Answer is C

Explanation

A. Instruct the client to avoid high-potassium foods: While important for long-term management, it is not the priority when the client is experiencing hyperkalemia, as immediate interventions are necessary to prevent complications.

B. Redraw the potassium to verify results: Redrawing the potassium may be necessary if there is concern about sample contamination or if the result is significantly different from what is expected. However, it is not the priority when the client is at risk of complications from hyperkalemia.

C. Check the client's blood pressure: This is the priority action because hyperkalemia can lead to cardiac dysrhythmias, including potentially life-threatening arrhythmias. Checking the blood pressure helps assess the client's cardiovascular status and any potential effects of hyperkalemia on cardiac function.

D. Obtain a serum sodium level: While monitoring electrolyte levels is important in ESRD, sodium levels are not the priority when the client is experiencing hyperkalemia. Monitoring potassium and managing its effects take precedence.

A. Recovery phase. B. Diuretic phase. C. Initiation phase. D. Oliguric phase. E. End phase.

Correct Answer is ["A","B","C","D"]

Explanation

A. Recovery phase: The recovery phase occurs after the oliguric phase and is characterized by the gradual improvement of renal function. During this phase, diuresis may occur as the kidneys begin to excrete waste and excess fluid more effectively.

B. Diuretic phase: The diuretic phase follows the oliguric phase and is characterized by increased urine output as the kidneys start to recover and regain their ability to concentrate urine. This phase can lead to electrolyte imbalances and dehydration if not managed properly.

C. Initiation phase: The initiation phase marks the onset of acute renal failure and is characterized by the initial insult or injury to the kidneys. This phase may be triggered by various factors such as hypotension, nephrotoxic medications, or sepsis.

D. Oliguric phase: The oliguric phase is the initial phase of acute renal failure and is characterized by decreased urine output (<400 mL/day). During this phase, waste products and electrolytes may accumulate in the body, leading to metabolic acidosis and fluid overload.

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A nurse caring for a client who is at home on hospice care. Exhibits At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with End Stage Renal Disease (ESRD) has a potassium level of 6.8 mEq/L. Which of the following priority actions should the nurse implement?

Correct Answer is C

Explanation

A nurse is teaching a client diagnosed with acute renal failure about how the disease progresses. The nurse should recognize that the teaching is effective when the client can accurately identify which phases of renal disease progression? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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A nurse is caring for a client on a mechanical ventilator receiving a neuromuscular blockade agent. The nurse should prioritize which action?

A nurse caring for a client who is at home on hospice care. Exhibits At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

A nurse caring for a client who is at home on hospice care.

Exhibits

At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.