The nurse realizes that which clients are at risk for intra-renal injury? (Select all that apply)

A client with congestive heart failure

A client taking vancomycin

A client with glomerulonephritis

A client with bladder cancer

A client with a traumatic injury directly onto the kidney

Answer and Explanation

Correct Answer : B,C,E

Choice A reason: Congestive heart failure can lead to prerenal injury due to decreased renal perfusion, but it is not a direct cause of intrarenal injury.

Choice B reason: Vancomycin is a nephrotoxic medication that can cause intrarenal injury. The drug can directly damage the renal tubules, leading to acute kidney injury.

Choice C reason: Glomerulonephritis involves inflammation of the glomeruli, which is a direct cause of intrarenal injury. This condition affects the kidney's filtering units, leading to impaired renal function.

Choice D reason: Bladder cancer is more associated with postrenal injury due to obstruction of urine flow, rather than intrarenal injury.

Choice E reason: A traumatic injury directly onto the kidney can cause damage to the renal tissue, leading to intrarenal injury. This type of injury affects the kidney itself and can result in acute kidney injury.

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Correct Answer is D

Explanation

Choice A reason: The ability to repeat three whispered words without difficulty is an assessment of auditory acuity, not a specific finding of the Rinne test. The Rinne test evaluates bone and air conduction of sound.

Choice B reason: Placing the tuning fork on top of the head is part of the Weber test, which assesses lateralization of sound. It is not part of the Rinne test.

Choice C reason: Minimal swaying when standing with feet together and eyes closed is an assessment of balance, known as the Romberg test. It is not related to the Rinne test.

Choice D reason: The Rinne test compares air conduction (next to the ear) with bone conduction (on the mastoid process). Normally, air conduction is heard longer than bone conduction, indicating normal hearing or sensorineural hearing loss. This is the correct expected finding for the Rinne test.

A. The nurse waits 5 minutes between administering prescribed eye drops. B. The nurse leaves the eye shield in place while the client sleeps. C. The nurse is instructing the client not to drive at night. D. The nurse encourages the client to exercise with 20 lb weights 1 day post-operatively.

Correct Answer is D

Explanation

Choice A reason: The nurse waiting 5 minutes between administering prescribed eye drops is a standard practice to allow each drop to be properly absorbed and avoid dilution of the medication. This intervention does not require any action from the charge nurse.

Choice B reason: Leaving the eye shield in place while the client sleeps helps protect the eye from potential injury or infection after surgery. This is a recommended practice and does not need intervention from the charge nurse.

Choice C reason: Instructing the client not to drive at night is a reasonable precautionary measure given the client's recent eye surgery and potential vision changes. This instruction does not warrant intervention from the charge nurse.

Choice D reason: Encouraging the client to exercise with 20 lb weights one day post-operatively is inappropriate and requires the charge nurse to intervene. Strenuous activity can increase intraocular pressure and compromise the healing process after cataract surgery. The client should avoid heavy lifting and follow the post-operative care instructions provided by the healthcare team.

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The nurse realizes that which clients are at risk for intra-renal injury? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

The nursing student is asked by the preceptor what are the expected findings of the Rinne test. What statement by the nursing student is correct?

Correct Answer is D

Explanation

The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

Correct Answer is D

Explanation

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