The nurse is assessing a client with a sodium level of 138 mEq/L (135-145 mEq/L), bounding pulses, blood pressure of 159/92 mmHg, pedal edema and confusion. Indicate which prescriptions ordered by the provider and nursing actions are essential, non-essential, or contraindicated.

Assess for symptoms of hyperglycemia

Assess for bilateral peripheral edema.

Measure intake and output every hour.

Review the client's most recent CBC results.

Hold furosemide

Place the client in Trendelenburg position

Answer and Explanation

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

Assess for symptoms of hyperglycemia – Non-essential: The client’s presentation is consistent with fluid overload and hypertension, not hyperglycemia. Assessing for hyperglycemia may be done but is not a priority.
Assess for bilateral peripheral edema – Essential: Bilateral edema is a key indicator of fluid overload and cardiovascular compromise, requiring immediate assessment.
Measure intake and output every hour – Essential: Accurate I&O monitoring is critical for managing fluid status in clients with edema and hypertension.
Review the client's most recent CBC results – Non-essential: While helpful for general assessment, CBC does not directly address the acute fluid overload and cardiovascular status.
Hold furosemide – Contraindicated: Furosemide, a loop diuretic, is typically indicated for fluid overload. Holding it could worsen edema and hypertension.
Place the client in Trendelenburg position – Contraindicated: Trendelenburg can increase venous return and worsen pulmonary edema or hypertension, making it unsafe for this client.

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Correct Answer is D

Explanation

A. Hypovolemic shock causes decreased renal perfusion and is associated with prerenal acute kidney injury, not post renal.

B. Long-term NSAID use can cause intrarenal acute kidney injury by damaging renal tissue through inhibition of prostaglandin synthesis and decreased renal blood flow.

C. Acute glomerulonephritis results in intrarenal acute kidney injury due to inflammation and damage to the glomeruli.

D. Benign prostatic hyperplasia (BPH) can cause urinary tract obstruction by compressing the urethra, leading to urinary retention and backflow of urine into the kidneys. This obstruction results in post renal acute kidney injury.

A. "I might cry uncontrollably and feel physically ill whenever I visit." B. "I might prepare for the loss by reducing the time I spend with my spouse." C. "I cannot believe that a merciful God would allow my leg to be amputated." D. "I may refuse to leave the bedside regardless of the reason."

Correct Answer is B

Explanation

A. Crying uncontrollably and physical illness reflect acute grief responses, not anticipatory grief.
B. Anticipatory grief occurs before an actual loss and may involve gradually detaching or preparing emotionally by reducing time spent with the loved one.
C. This reflects spiritual distress or anger rather than anticipatory grief.
D. Refusing to leave the bedside demonstrates denial or difficulty coping, not healthy anticipatory grieving.

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Heart Rate	105 beats/minute.
Blood Pressure	130/85 mmHg
Pain	6 on a 0-10 scale
Temperature	101.3 F (38.5 C)
White Blood Cell (WBC)	12,000 mm3 (Ref: 4,000-10,000 mm3)
Platelet Count	150,000 mcl (Ret: 150,000-400,000 mcl)

The nurse is assessing a client with a sodium level of 138 mEq/L (135-145 mEq/L), bounding pulses, blood pressure of 159/92 mmHg, pedal edema and confusion. Indicate which prescriptions ordered by the provider and nursing actions are essential, non-essential, or contraindicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for several clients with acute kidney injury. Which client is most at risk for developing post renal acute kidney injury?

Correct Answer is D

Explanation

The nurse is educating a client's spouse about anticipatory grief. Which statement made by the spouse indicates understanding?

Correct Answer is B

Explanation

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