BASIC ECG b) Atropine
12 seconds
1. Sinus bradycardia originates in what part of the electrical
conduction system?
a) AV node
b) SA node
c) Bundle Branches
d) Bundle of His
2. You're analyzing a patient's ECG reading. What should be
found in the rhythm for it to be considered Sinus
Bradycardia (select all that apply):
a) One p wave present in front of every QRS complex
b) Atrial rate 60 and ventricular rate of 60
c) Regular atrial and ventricular rate
d) Atrial rate 40 and ventricular rate of 40
e) Regular atrial rate and irregular ventricular rate
f) PR interval 0.14 seconds
g) PR interval 0.36 seconds
h) QRS interval 0.08 seconds
i) QRS interval 0.16 seconds
3. You obtain an ECG on a patient and the rhythm is sinus
bradycardia with a rate of 52 bpm. Your NEXT nursing action
is to?
a) Prepare to administer Atropine IV push
b) Set-up for transcutaneous pacing
c) Assess the patient
d) Call a rapid response
Rationale: Assess the patient. When discovering sinus
bradycardia, the nurse should determine if the patient is
having symptoms. Not all cases of this rhythm require
medical treatment.
4. Your patient is experiencing extreme fatigue, hypotension,
palpations, and shortness of breath. You obtain an ECG and
discover a rhythm of sinus bradycardia with a rate of 40
bpm. What finding below could be causing this condition?
a) Potassium level of 3.9 meq/L
b) Lisinopril 10 mg BID PO
c) Blood glucose 84
d) Digoxin 0.125 mg PO daily
Rationale: Digoxin slows down the heart rate and can lead
to bradycardia.
5. Which of the following is NOT a treatment for symptomatic
sinus bradycardia?
a) Dopamine
a) 0.
c) Synchronized cardioversion b) 0.04 seconds
d) Transcutaneous pacing c) 0.16 seconds
6. A patient is experiencing sinus bradycardia with a rate of 34 d) 0.20 seconds
bpm and blood pressure of 78/42. The patient reports 12. A client has just undergone an electrocardiogram (ECG), the
symptoms of chest pain, has cool and clammy skin, nurse notes that the QRS complex is measured to be 0.09
dyspnea, and feels like they may faint. The nurse prepares seconds. What is the first action the nurse should take?
to administer Atropine per a standing physician's order for a) Call the physician
the patient's symptomatic bradycardia. How will the nurse b) Administer oxygen
administer this medication? c) Administer dopamine
a) 3 mg IV push every 3-5 minutes, max dose of 5 mg d) Place on a cardiac monitor to check for arrhythmias
b) 2 mg IV push every 1-2 minutes, max dose of 3 mg e) The nurse should document this finding
c) 3-5 mg IV push every 1 minute, max dose 10 mg Rationale: This is a normal finding, the QRS should have a
d) 1 mg IV push every 3-5 minutes, max dose of 3 mg duration between 0.6-0.12 seconds.
Rationale: Atropine for symptomatic bradycardia should be 13. You are taking care of an elderly patient who is hospitalized
given as 1 mg IV push every 3-5 minutes, max dose of 3 mg. for sudden onset of severe, diffuse abdominal pain out of
7. Referring back to the previous question (6), Atropine was proportion to the patient's abdominal physical exam that is
ineffective for treating the bradycardia. The patient is still also accompanied by rectal bleeding and palpitations. You
symptomatic with a rate 35 bpm. What other options could obtain an ECG and notice a tachycardic, irregularly irregular
be considered for the patient? Select all that apply: rhythm without any distinct P waves. Which of the following
a) Transcutaneous pacing is the most likely cardiac rhythm seen on this patient's ECG?
b) Amiodarone Infusion a) First-degree heart block
c) Dopamine Infusion b) Sick sinus syndrome
d) Epinephrine Infusion c) Atrial fibrillation (A-fib)
8. Which medication below should not be used for the d) Atrial flutter
treatment of sinus bradycardia in a patient with a e) Complete heart block
transplanted heart? 14. A patient presents with thirty minute history of substernal
a) Isoproterenol chest pain that radiates to his left jaw. Which of the
b) Atropine following EKG changes would you expect in this patient if
c) Epinephrine his troponin level came back positive at 0.89ngmL?
d) Glucagon a) PR widening
9. Use the figure at the top of the quiz to answer the next few b) PR shortening
questions: What is the rate of the rhythm above? c) ST depression
a) 60 bpm d) ST elevation
b) 30 bpm e) QT prolongation
c) 50 bpm Rationale: Substernal chest pain that radiates to the jaw is
d) 40 bpm classic of myocardial infarction. Elevated troponin and EKG
10. What is the PR interval of the rhythm above? changes help confirm the diagnosis (reference levels are
a) 0.04 seconds about 0.01ngmL. ST segment elevation is classically seen in
b) 0.12 seconds myocardial infarctions that result in positive troponin.
c) 0.16 seconds 15. You are a nurse taking care of a patient in the emergency
d) 0.20 seconds room. Among other acute labwork and imaging, you obtain
11. What is the QRS interval of the rhythm above? an electrocardiogram (ECG) of the patient. The ECG shows
 Osborn waves. Which of the following is the most common
cause of Osborn waves on ECG?
a) Lead poisoning
b) Hypothermia
c) Hyperthermia
d) Ethanol toxicity
e) Carbon monoxide poisoning
Rationale: The correct answer is "hypothermia." Osborn
waves on electrocardiogram are the pathognomonic finding
associated with hypothermia (to a core body temperature of
lower than 32 C). Osborn waves are observed as upward
deflections in the ECG reading between the QRS and ST
intervals with an elevation at the S point (which is
sometimes also referred to as the J point). While
hypothermia is the most common cause of Osborn waves,
they may also be observed in patients with coronary
vasospasm, hypercalcemia, ventricular fibrillation, or brain
trauma.
Neither hyperthermia, ethanol toxicity, carbon monoxide
poisoning, nor lead poisoning are associated with Osborn
waves on ECG.
16. An EKG of your patient shows peaked T-waves. This finding
correlates to which electrolyte abnormality?
a) High calcium
b) Low potassium
c) High sodium
d) Low sodium
e) High potassium
Rationale: Peaked T-waves are a warning sign for elevated
levels of potassium in the body. On the other hand, flattened
T-waves are potentially indicative of low levels of potassium.
Hyperkalemia (high potassium) is a potentially dangerous
condition that can lead to cardiac abnormalities and
potentially death.
17. What is the most common EKG finding in a patient with a
pulmonary embolism?
a) Sinus bradycardia
b) Sinus tachycardia
c) ST depression
d) ST elevation
Rationale: Sinus tachycardia is the most common EKG
finding in a pulmonary embolism. This represents the heart
beating faster as an infarction occurs within the lung tissue.
Peaked T waves are seen in hyperkalemia. ST elevation is
seen in myocardial infarction, and ST depression is seen in
myocardial ischemia. Sinus bradycardia would not be the
expected finding in a PE.
DKA AND HHS
1. The elderly patient with type 2 diabetes mellitus presents to
the clinic with a fever and productive cough. The diagnosis
of pneumonia is made. You notice tenting skin, deep tongue
furrows, and vital signs of 110/80 mm Hg, 120
beats/minute, and 24 breaths/minute. What assessment is
important for you to obtain?
a) Blood glucose
b) Orthostatic blood pressures
c) Urine ketones
d) Temperature
Rationale: HHS is typically seen in patients with type 2
diabetes and infection, such as pneumonia. The main
presenting sign is a glucose level above 600 mg/dL. Enough
evidence of dehydration already exists that orthostatic vital
sign assessments are not a priority, and they are often
inaccurate in the elderly due to poor vascular tone. Patients
with HHS do not have elevated ketone levels, which is a key
distinction between HHS and DKA. Temperature will
eventually be taken but is often blunted in the elderly and
diabetics. An infectious diagnosis has already been made.
The glucose level for appropriate fluid and insulin treatment
is the priority.
2. The patient with HHS presented with a glucose level of 800
mg/dL and is started on IV fluids and insulin. What action do
you anticipate when the patient's glucose reaches 250
mg/dL?
a) Administer an intravenous (IV) solution with 5%
dextrose.
b) Administer sodium polystyrene sulfate (Kayexalate).
c) Slow the IV infusion rate to 40 mL/hour.
d) Assess cardiac monitoring for peaked T waves
Rationale: When blood glucose levels fall to approximately
250 mg/dL, IV fluids containing glucose are administered to
prevent hypoglycemia. Kayexalate (for cation exchange) is
used in the treatment of hyperkalemia, which causes peaked
T waves on cardiac monitoring. In HHS hypokalemia may
result from insulin moving the potassium intracellularly.
Fluid replacement remains a priority, but it is given with
dextrose. The infusion rate of 40 mL/hour keeps the vein
open, but it is not the appropriate replacement rate.
3. What is a typical finding of hyperosmolar hyperglycemic
syndrome (HHS)?
a) Occurs in type 1 diabetes as the presenting
symptom
b) Slow onset resulting in a blood glucose level
greater than 600 mg/dL
c) Ketone bodies higher than 4+ in urine
d) Signs and symptoms of diabetes insipidus
Rationale: Slow onset resulting in a blood glucose level
greater than 600 mg/dL
HHS has a slower onset than diabetic ketoacidosis. HHS is
often related to impaired thirst sensation, inadequate fluid
intake, or functional inability to replace fluids. Because of
the slower onset, the blood glucose levels can be quite high
(more than 600 mg/dL) before diagnosis. HHS is seen in type
2 diabetics, and there is enough circulating insulin to
prevent ketoacidosis. Diabetes insipidus is related to
inadequate antidiuretic hormone secretion or kidney
response with dilute, frequent urination. It is not related to
HHS.
4. A diabetic patient has a serum glucose level of 824 mg/dL
(45.7 mmol/L) and is unresponsive. After assessment of the
patient, you suspect DKA rather than HHS based on the
finding of
a) Polyuria.
b) Severe dehydration.
c) Rapid, deep respirations.
d) Decreased serum potassium.
Rationale: Rapid, deep respirations are Kussmaul's and are
the body's attempt to reverse metabolic acidosis through
exhalation of excess carbon dioxide. Symptoms of DKA
include manifestations of dehydration, such as poor skin
turgor, dry mucous membranes, tachycardia, and
orthostatic hypotension. Kussmaul respirations (rapid, deep
breathing associated with dyspnea) are the body's attempt
to reverse metabolic acidosis through exhalation of excess
carbon dioxide. Acetone is detected on the breath as a
sweet, fruity odor
5. What is a finding in DKA that is not seen in hyperosmolar
hyperglycemic syndrome (HHS)?
a) Glucose level above 400 mg/dL
b) Hyperkalemia
c) Ketones in blood
d) Urine output of 30 mL/h
Rationale: The main difference between the two conditions
is that ketone bodies are absent or minimal in HHS because
the body has enough insulin to prevent ketoacidosis. Both
have high glucose levels, although the level in HHS tends to
be higher (above 600 mg/dL). Hypokalemia is possible in
both, although it is more likely and serious in DKA. Urine
output of 30 mL/hr is normal obligatory output; both
conditions are likely to have dehydration and decreased
output.
6. Which assessment is the most sensitive indicator that the IV
fluid administration may be too rapid when treating a
patient with DKA and a history of renal disease?
a) Pedal edema
b) Tachypnea
c) Urine output of 40 mL/hour
d) Change in the level of consciousness
Rationale: Too rapid fluid replacement can lead to
hyponatremia and cerebral edema. Pedal edema is a later
and relatively insignificant sign. In a bedridden patient,
edema is more evident in the sacral area. The Kussmaul
respirations are expected; crackles auscultated in the lungs
are a more sensitive indicator. The desired urine output for
adequate hydration is 30 to 60 mL/hr.
7. The patient presents to the emergency department with a
glucose level of 400 mg/dL, ketone result of 2+, and rapid
respirations with a fruity odor. What finding do you
anticipate?
a) pH below 7.30
b) Urine specific gravity below 1.005
c) High sodium bicarbonate levels
d) Low blood urea nitrogen (BUN) level
Rationale: The patient is in metabolic acidosis, which is a pH
below 7.35. Dehydration results in a high urine specific
gravity (at the upper end of the normal range, or above
1.025 to 1.030). Sodium bicarbonate levels are low in
metabolic acidosis. The dehydration that occurs with DKA
elevates the BUN level.
8. The patient in the emergency department is diagnosed with
diabetic ketoacidosis. Which laboratory value is essential for
you to monitor?
a) Magnesium (Mg)
b) Hemoglobin (Hb)
c) White blood cells (WBCs)
d) Potassium (K)
Rationale: Even if the patient has normal potassium levels,
there can be significant hypokalemia when insulin is
administered as it pushes the serum potassium
intracellularly. This can lead to life-threatening
hypokalemia. The other options are not as significant.
9. The patient with type 1 diabetes arrives in the emergency
department with a glucose level of 390 mg/dL and positive
result for ketones. Vital signs are 110/70 mm Hg, 120
beats/minute, and 28 deep, sighing respirations/minute.
What is the priority need for the patient?
a) Oxygen
b) Intravenous (IV) fluids
c) Albuterol (Ventolin)
d) Metformin (Glucophage)
Rationale: A patient in diabetic ketoacidosis (DKA) needs IV
fluids and insulin to stop the tissue breakdown resulting in
ketone bodies and acidosis. The initial goal is fluid and
electrolyte balance. Kussmaul respirations indicate the body
is attempting to compensate by blowing off the carbon
dioxide, but it is ineffective as long as the body continues to
break down the ketone bodies and remains in metabolic
acidosis.
10. The patient has type 1 diabetes mellitus and is found
unresponsive with cool and clammy skin. What action is a
priority?
a) Obtain a serum glucose level.
b) Give hard candy under the tongue.
c) Administer glucagon per standing order.
d) Notify the health care provider.
Rationale: The patient has signs and symptoms of
hypoglycemia for which treatment should be the priority.
Glucagon stimulates a strong hepatic response to convert
glycogen to glucose and therefore makes glucose rapidly
available. Waiting for a serum result (up to an hour) is
improper because brain cells continue to die from a lack of
glucose. Nothing solid should be placed in the mouth when
the patient has an altered level of consciousness and can
aspirate. With obvious symptoms, emergent treatment
takes priority over notifying the health care provider.
11. The patient had a hypoglycemic episode and is treated with
a concentrated glucose oral tablet. Fifteen minutes later the
capillary glucose level (Accu-Check) is 150 mg/dL. What
action should you take?
a) Administer a second bolus of glucose solution.
b) Administer regular insulin per sliding scale.
c) Have the patient eat peanut butter and toast.
d) Obtain a serum glucose level.
Rationale: The patient has had an appropriate response to
the glucose. Now a complex carbohydrate is needed to
prevent hypoglycemia from reoccurring. There is no need for
a second bolus of glucose because the result is within
normal range. Insulin is not given, even though the glucose
level is slightly elevated. The short-acting glucose is
metabolized and insulin administration can increase the risk
of a second hypoglycemic reaction. A serum confirmation of
the level can be obtained but is not the priority.
12. The patient is managed with NPH and regular insulin
injections before breakfast and before dinner. When is the
patient most likely to have a hypoglycemic reaction?
a) After breakfast
b) Before lunch
c) During lunch
d) After lunch
Rationale: The regular insulin peak occurs about 2 to 3 hours
with a duration of 5 to 6 hours. If too much insulin or not
enough food is given, the most likely time of hypoglycemia is
before lunch, when the regular insulin is still present, the
NPH has its onset, and the breakfast food has been
metabolized.
13. Which symptoms reported by a patient with diabetes
mellitus are most important to follow-up?
a) "My vision has been getting fuzzier over the past
year."
b) "I cannot read the small print anymore."
c) "There is something like a veil of blackness coming
across my vision."
d) "I have yellow discharge from one eye."
Rationale: Diabetic retinopathy, particularly proliferative
retinopathy, can cause retinal detachment, which has the
 classic new symptom of a veil coming across the field of
vision. This requires emergency treatment. Chronic blurry
vision can be cataracts and is not emergent. Change in the
ability to read things near to the eye (presbyopia or
farsightedness) is an age-related change and not emergent.
Conjunctivitis needs treatment but is not as emergent as
retinal detachment.
14. What is the best teaching for a patient who is newly
diagnosed with diabetes mellitus type 2?
a) Read a Snellen chart yearly.
b) Be checked out for presbycusis.
c) Notify the doctor if your vision has color distortion.
d) See an ophthalmologist for a dilated eye
examination yearly.
Rationale: The earliest and most treatable stages of diabetic
retinopathy often produce no changes in the vision. Because
of this, the patient with type 2 diabetes should have a
dilated eye examination by an ophthalmologist at the time
of diagnosis and annually thereafter for early detection and
treatment.
15. You are beginning to teach a diabetic patient about the
vascular complications of diabetes. Which information is
appropriate for you to include?
a) Macroangiopathy does not occur in type 1 diabetes
but does affect type 2 diabetics who have severe
disease.
b) Microangiopathy is specific to diabetes and most
commonly affects the capillary membranes of the
eyes, kidneys, and skin.
c) Renal damage resulting from changes in large and
medium-sized blood vessels can be prevented by
careful glucose control.
d) Macroangiopathy causes slowed gastric emptying
and the sexual impotency experienced by most
patients with diabetes
Rationale: Microangiopathy occurs in type 1 and type 2
diabetes mellitus. When it affects the eyes, it is called
diabetic retinopathy. When kidneys are affected, the patient
has nephropathy. When the skin is affected, it can lead to
diabetic foot ulcers. Sexual impotency and slowed gastric
emptying result from microangiopathy.
16. Laboratory results are available for a 54-year-old patient
with a 15-year history of diabetes. Which result follows the
expected pattern accompanying macrovascular disease as a
complication of diabetes?
a) Increased triglyceride levels
b) Decreased low-density lipoprotein levels
c) Increased high-density lipoprotein levels
d) Decreased very-low-density lipoprotein levels
Rationale: Macrovascular complications of diabetes include
changes in medium- and large-sized blood vessels. They
include cerebrovascular, cardiovascular, and peripheral
vascular disease. Increased triglyceride levels are associated
with these macrovascular changes. For this reason, the
patient should limit the amount of fat in the diet.
17. What therapies are appropriate for patients with diabetes
mellitus (select all that apply)?
a) Use of statins to treat dyslipidemia
b) Use of diuretics to treat nephropathy
c) Use of angiotensin-converting enzyme (ACE)
inhibitors to treat nephropathy
d) Use of laser photocoagulation to treat retinopathy
e) Use of protein restriction in patients with early signs
of nephropathy
Rationale: In patients with diabetes who have
microalbuminuria or macroalbuminuria, ACE inhibitors (-
prils) or angiotensin II receptor antagonists (ARBs) (-sartans)
should be used. Both of these drug classes are used to treat
hypertension. The statin drugs are the most widely used
lipid-lowering drugs. Laser photocoagulation therapy is
indicated to reduce the risk of vision loss in patients with
proliferative retinopathy, macular edema, and in some cases
of nonproliferative retinopathy.
18. The patient has diabetes mellitus and macroalbuminuria.
The patient asks you why the physician is prescribing the
angiotensin-converting enzyme (ACE) inhibitor lisinopril
(Zestril) for him even though his blood pressure is well-
controlled. What is your response?
a) It helps prevent hypertension as diabetics are prone
to it.
b) ACE inhibitors delay the progression of
nephropathy in patients with diabetes.
c) ACE inhibitors prevent macrovascular
complications.
d) ACE inhibitors help prevent atherosclerosis.
Rationale: ACE inhibitors and angiotensin II receptor
antagonists (ARBs) are used to treat hypertension and delay
the progression of nephropathy in patients with diabetes.
ACE inhibitors are not used prophylactically. ACE inhibitors
do not affect macrovascular complications. Nephropathy is
a microvascular complication.
19. What is most helpful in the prevention of nephropathy in a
patient with diabetes mellitus?
a) Acid-ash diet
b) Ensuring adequate fluid intake for renal perfusion
c) Preventing obstruction from benign prostatic
hyperplasia (BPH)
d) Stopping smoking
Rationale: Risk factors for diabetic nephropathy include
hypertension, genetic predisposition, smoking, and chronic
hyperglycemia. Diabetic nephropathy is an intrarenal
microvascular complication in which the glomeruli of the
kidney are damaged. The kidney receives about 25% of the
cardiac output, and inadequate fluids or shock resulting in
adequate perfusion is a prerenal cause. BPH is a post-renal
cause of kidney pathology.
20. Which elevated laboratory finding is the best indication of
potential diabetic nephropathy?
a) Blood urea nitrogen (BUN) level
b) Urine albumin-to-creatinine ratio
c) Urine specific gravity
d) Chloride (Cl-) level
Rationale: Screening for nephropathy depends on the
urinary albumin-to-creatinine ratio and a serum creatinine
level. BUN alone, without correction to creatinine, can
indicate many other issues, including dehydration and liver
function. Unless there is renal failure, urine specific gravity is
more indicative of dehydration.
21. The patient with diabetes and shortness of breath is
brought from the nursing home to the hospital emergency
department. The electrocardiogram (ECG) shows evidence
of a myocardial infarction (MI), but the patient denied ever
having chest pain. Which is the best explanation of what
happened?
a) The patient had a "silent" MI related to autonomic
neuropathy.
b) The patient had chest pain but forgot because of
dementia.
 c) The patient minimized the chest pain because he
was worried about costs.
d) The patient has the psychologic defense mechanism
of denial.
Rationale: Cardiovascular abnormalities associated with
autonomic neuropathy include painless myocardial
infarction. Shortness of breath related to decreased cardiac
functioning can be the first overt sign or symptom
22. The patient with diabetes reports tingling and burning in the
lower extremities at night. The patient asks you why the
primary health care provider prescribed the selective
serotonin reuptake inhibitor (SSRI) duloxetine (Cymbalta).
What is the best response?
a) The doctor thought the discomfort was causing the
patient to be depressed.
b) The drug is known to improve patients' moods and
enhance coping.
c) It regulates pain by affecting neurotransmitters
that transmit pain through the spine.
d) It deadens the sensitivity to peripheral nerve
endings.
Rationale: SSRI drugs work by inhibiting the reuptake of
norepinephrine and serotonin, which are neurotransmitters
that are believed to play a role in the transmission of pain
through the spinal cord. Duloxetine is thought to relieve pain
by increasing the levels of serotonin and norepinephrine,
which improves the body's ability to regulate pain.
23. The male patient with diabetes and heart disease confides
to you that he can no longer have an erection. What is the
reason for these changes?
a) It is a normal part of aging and is relieved with
sildenafil (Viagra).
b) It usually is related to emotions and is a temporary
problem.
c) It is often the first sign of diabetic autonomic
neuropathy.
d) It indicates that the patient has developed a
neurogenic bladder.
Rationale: Erectile dysfunction (ED) is common and often is
the first manifestation of autonomic failure. ED is a common
long-term complication of diabetes. Neurogenic bladder is
related to urinary retention
24. Which lower extremity or foot finding is a sign of sensory
neuropathy in a patient with diabetes mellitus?
a) Dusky when legs are dependent
b) Pitting pedal edema
c) Intermittent claudication
d) Strong pedal pulse
Rationale: Peripheral arterial disease (PAD) is caused by a
reduction of blood flow to the lower extremities. Classic
signs include intermittent claudication, pain at rest, cold
feet, loss of hair, delayed capillary filling, and dependent
rubor. Dusky legs when they are dependent, pitting pedal
edema, and a strong pedal pulse are signs of peripheral
venous disease.
25. An 18-year-old female client, 5′4′′tall, weighing 113 kg,
comes to the clinic for a non-healing wound on her lower
leg, which she has had for two (2) weeks. Which disease
process should the nurse suspect the client has developed?
a) Type 1 diabetes.'
b) Type 2 diabetes.
c) Gestational diabetes.
d) Acanthosis nigricans
Rationale: Type 2 diabetes is a disorder usually occurring
around the age of 40, but it is now being detected in
children and young adults as a result of obesity and
sedentary lifestyles. Non healing wounds are a hallmark sign
of type 2 diabetes. This client weighs 248.6 pounds and is
short.
26. The nurse administered 28 units of Humulin N, an
intermediate-acting insulin, to a client diagnosed with type
1 diabetes at 1600. Which intervention should the nurse
implement?
a) Ensure the client eats the bedtime snack.
b) Determine how much food the client ate at lunch.
c) Perform a glucometer reading at 0700.
d) Offer the client protein after administering insulin.
Rationale: Humulin N peaks in 6 to 8 hours, making the
client at risk for hypoglycemia around midnight, which is
why the client should receive a bedtime snack. This snack
will prevent nighttime hypoglycemia.
27. The client diagnosed with type 1 diabetes is receiving
Humalog, a rapid-acting insulin, by sliding scale. The order
reads blood glucose level: <150, zero (0) units; 151 to 200,
three (3) units; 201 to 250, six (6) units; >251, contact
health-care provider. The UAP reports to the nurse the
client's glucometer reading is 189. How much insulin should
the nurse administer to the client?
Answer: Three (3) units.
The client's result is 189, which is between151 and 200, so
the nurse should administer3 units of Humalog insulin
subcutaneously
28. The nurse is discussing the importance of exercising with a
client diagnosed with type 2 diabetes whose diabetes is well
controlled with diet and exercise. Which information should
the nurse include in the teaching about diabetes?
a) Eat a simple carbohydrate snack before exercising.
b) Carry peanut butter crackers when exercising.
c) Encourage the client to walk 20 minutes three (3)
times a week.
d) Perform warm up and cool-down exercises.
Rationale: All clients who exercise should perform warmup
and cool-down exercises to help prevent muscle strain and
injury.
29. The nurse is assessing the feet of a client with long-term
type 2 diabetes. Which assessment data warrant immediate
intervention by the nurse?
a) The client has crumbling toenails.
b) The client has athlete's foot.
c) The client has a necrotic big toe.
d) The client has thickened toenails
Rationale: A necrotic big toe indicates "dead" tis-sue. The
client does not feel pain, does not realize the injury, and
does not seek treatment. Increased blood glucose levels
decrease the oxygen supply needed to heal the wound and
increase the risk for developing an infection.
30. The home health nurse is completing the admission
assessment for a 76-year-old client diagnosed with type 2
diabetes controlled with 70/30 insulin. Which intervention
should be included in the plan of care?
a) Assess the client's ability to read small print.
b) Monitor the client's serum PT level.
c) Teach the client how to perform a hemoglobin A1c
test daily.
d) Instruct the client to check the feet weekly.
Rationale: Age-related visual changes and diabetic
retinopathy could cause the client to have difficulty in
reading and drawing up insulin dosage accurately.
31. The client with type 2 diabetes controlled with biguanide
oral diabetic medication is scheduled for a (CT) scan with
contrast of the abdomen to evaluate pancreatic function.
Which intervention should the nurse implement?
a) Provide a high-fat diet 24 hours prior to test.
b) Hold the biguanide medication for 48 hours prior
to test.
c) Obtain an informed consent form for the test
d) .Administer pancreatic enzymes prior to the test.
Rationale: Biguanide medication must be held for a test with
contrast medium because it increases the risk of lactic
acidosis, which leads to renal problems.
32. The diabetic educator is teaching a class on diabetes type 1
and is discussing sick-day rules. Which interventions should
the diabetes educator include in the discussion? Select all
that apply.
a) Take diabetic medication even if unable to eat the
client's normal diabetic diet.
b) If unable to eat, drink liquids equal to the client's
normal caloric intake.
c) It is not necessary to notify the health-care provider
if ketones are in the urine.
d) Test blood glucose levels and test urine ketones
once a day and keep a record.
e) Call the health-care provider if glucose levels are
higher than 180 mg/dL.
Rationale:
A: The most important issue to teach clients is to take insulin
even if they are unable to eat. Glucose levels are in-creased
with illness and stress.
B: The client should drink liquids such as regular cola or
orange juice, or eat regular gelatin, which provide enough
glucose to prevent hypoglycemia when receiving insulin.
E: The HCP should be notified if the blood glucose level is this
high. Regular insulin may need to be prescribed to keep the
blood glucose level within acceptable range
33. The nurse at a free standing health care clinic is caring for a
56-year-old male client who is homeless and is a type 2
diabetic controlled with insulin. Which action is an example
of client advocacy?
a) Ask the client if he has somewhere he can go and
live.
b) Arrange for someone to give him insulin at a local
homeless shelter.
c) Notify Adult Protective Services about the client's
situation.
d) Ask the HCP to take the client off insulin because he
is homeless.
Rationale: Client advocacy focuses support on the client's
autonomy. Even if the nurse disagrees with his living on the
street, it is the client's right. Arranging for someone to give
him his insulin provides for his needs and allows his choices
34. The nurse is developing a care plan for the client diagnosed
with type 1 diabetes. The nurse identifies the problem "high
risk for hyperglycemia related to non-compliance with the
medication regimen." Which statement is an appropriate
short-term goal for the client?
a) The client will have a blood glucose level between
90 and 140 mg/dL.
b) The client will demonstrate appropriate insulin
injection technique.
c) The nurse will monitor the client's blood glucose
levels four (4) times a day.
d) The client will maintain normal kidney function with
30-mL/hr. urine output.
Rationale: The short-term goal must address the response
part of the nursing diagnosis, which is "high risk for
hyperglycemia," and this blood glucose level is within
acceptable ranges for a client who is non-compliant.
35. The client diagnosed with type 2 diabetes is admitted to the
intensive care unit with hyperosmolar hyperglycemic
nonketonic syndrome (HHNS) coma. Which assessment data
should the nurse expect the client to exhibit?
a) Kussmaul's respirations.
b) Diarrhea and epigastric pain.
c) Dry mucous membranes.
d) Ketone breath odor.
Rationale: Dry mucous membranes are a result of the
hyperglycemia and occur with both HHNS and DKA.
36. The elderly client is admitted to the intensive care
department diagnosed with severe HHNS. Which
collaborative intervention should the nurse include in the
plan of care?
a) Infuse 0.9% normal saline intravenously.
b) Administer intermediate-acting insulin.
c) Perform blood glucometer checks daily.
d) Monitor arterial blood gas results.
Rationale: The initial fluid replacement is 0.9%normal saline
(an isotonic solution) intravenously, followed by 0.45%
saline. The rate depends on the client's fluid volume status
and physical health, especially of the heart.
37. Which electrolyte replacement should the nurse anticipate
being ordered by the health-care provider in the client
diagnosed with DKA who has just been admitted to the ICU?
a) Glucose.
b) Potassium.
c) Calcium.
d) Sodium
Rationale: The client in DKA loses potassium from increased
urinary output, acidosis, catabolic state, and vomiting.
Replacement is essential for preventing cardiac
dysrhythmias secondary to hypokalemia
38. The client diagnosed with HHNS was admitted yesterday
with a blood glucose level of 780 mg/dL. The client's blood
glucose level is now 300 mg/dL. Which intervention should
the nurse implement?
a) Increase the regular insulin IV drip.
b) Check the client's urine for ketones.
c) Provide the client with a therapeutic diabetic meal.
d) Notify the HCP to obtain an order to decrease
insulin.
Rationale: When the glucose level is decreased to around
300 mg/dL, the regular insulin infusion therapy is decreased.
Subcutaneous insulin will be administered per sliding scale.
39. The client diagnosed with type 1 diabetes is found lying
unconscious on the floor of the bathroom. Which
intervention should the nurse implement first?
a) Administer 50% dextrose IVP.
b) Notify the health-care provider.
c) Move the client to the ICU.
d) Check the serum glucose level.
Rationale: The nurse should assume the client is
hypoglycemic and administer IVP dextrose, which will rouse
the client immediately. If the collapse is the result of
hyperglycemia, this additional dextrose will not further
injure the client.
40. Which assessment data indicate the client diagnosed with
diabetic ketoacidosis is responding to the medical
treatment?
a) The client has tented skin turgor and dry mucous
membranes.
b) The client is alert and oriented to date, time, and
place.
c) The client's ABG results are pH 7.29, PaCO2 44,
HCO315.
d) The client's serum potassium level is 3.3 mEq/L.
Rationale: The client's level of consciousness can be altered
because of dehydration and acidosis. If the client's
sensorium is intact, the client is getting better and
responding to the medical treatment.
41. The UAP on the medical floor tells the nurse the client
diagnosed with DKA wants something else to eat for lunch.
Which intervention should the nurse implement?
a) Instruct the UAP to get the client additional food.
b) Notify the dietitian about the client's request.
c) Request the HCP increase the client's caloric intake.
d) Tell the UAP the client cannot have anything else.
Rationale: The client will not be compliant with the diet if he
or she is still hungry. Therefore, the nurse should request the
dietitian talk to the client to try to adjust the meals so the
client will adhere to the diet.
42. The emergency department nurse is caring for a client
diagnosed with HHNS who has a blood glucose of 680
mg/dL. Which question should the nurse ask the client to
determine the cause of this acute complication?
a) "When is the last time you took your insulin?"
b) "When did you have your last meal?"
c) "Have you had some type of infection lately?"
d) "How long have you had diabetes?
Rationale: The most common precipitating factor is
infection. The manifestations may be slow to appear, with
onset ranging from 24 hours to 2 weeks
43. The nurse is discussing ways to prevent diabetic keto
acidosis with the client diagnosed with type 1 diabetes.
Which instruction is most important to discuss with the
client?
a) Refer the client to the American Diabetes
Association.
b) Do not take any over-the-counter medications.
c) Take the prescribed insulin even when unable to
eat because of illness.
d) Explain the need to get the annual flu and
pneumonia vaccines.
Rationale: .Illness increases blood glucose levels; therefore,
the client must take insulin and consume high-carbohydrate
foods such as regular Jell-O, regular popsicles, and orange
juice
44. The charge nurse is making client assignments in the
intensive care unit. Which client should be assigned to the
most experienced nurse?
a) The client with type 2 diabetes who has a blood
glucose level of 348 mg/dL.
b) The client diagnosed with type 1 diabetes who is
experiencing hypoglycemia.
c) The client with DKA who has multifocal premature
ventricular contractions.
d) The client with HHNS who has a plasma osmolarity
of 290 mOsm/L.
Rationale: Multifocal PVCs, which are secondary to
hypokalemia and can occur in clients with DKA, are a
potentially life-threatening emergency. This client needs an
experienced nurse.
45. Which arterial blood gas results should the nurse expect in
the client diagnosed with diabetic ketoacidosis?
a) pH 7.34, PaO299, PaCO2 48, HCO324.
b) pH 7.38, PaO295, PaCO240, HCO322.
c) pH 7.46, PaO285, PaCO230, HCO326.
d) pH 7.30, PaO290, PaCO230, HCO318.
Rationale: This ABG indicates metabolic acidosis, which is
expected in a client diagnosed with diabetic ketoacidosis.
46. The client is admitted to the ICU diagnosed with DKA. Which
interventions should the nurse implement? Select all that
apply.
a) Maintain adequate ventilation.
b) Assess fluid volume status.
c) Administer intravenous potassium.
d) Check for urinary ketones.
47. A client is brought to the emergency department in an
unresponsive state, and a diagnosis of hyperglycemic
hyperosmolar state (HHS) is made. The nurse would
immediately prepare to initiate which anticipated health
care provider's prescription
a) Endotracheal intubation
b) 100 units of NPH insulin
c) Intravenous infusion of normal saline
d) Intravenous infusion of sodium bicarbonate
Rationale: The primary goal of treatment in hyperglycemic
hyperosmolar state (HHS) is to rehydrate the client to
restore fluid volume and to correct electrolyte deficiency.
Intravenous fluid replacement is similar to that administered
in diabetic ketoacidosis (DKA) and begins with IV infusion of
normal saline. Regular insulin, not NPH insulin, would be
administered. The use of sodium bicarbonate to correct
acidosis is avoided because it can precipitate a further drop
in serum potassium levels. Intubation and mechanical
ventilation are not required to treat HHS.
48. A client with a diagnosis of diabetic ketoacidosis (DKA) is
being treated in the emergency department. Which findings
would the nurse expect to note as confirming this
diagnosis? Select all that apply.
a) Increase in pH
b) Comatose state
c) Deep, rapid breathing
d) Decreased urine output
e) Elevated blood glucose level
f) Low plasma bicarbonate level
Rationale: In DKA, the arterial pH is lower than 7.35, plasma
bicarbonate is lower than 15 mEq/L, the blood glucose level
is higher than 250 mg/dL, and ketones are present in the
blood and urine. The client would be experiencing polyuria,
and Kussmaul's respirations (deep and rapid breathing
pattern) would be present. A comatose state may occur if
DKA is not treated, but coma would not confirm the
diagnosis.
49. The nurse teaches a client with diabetes mellitus about
differentiating between hypoglycemia and ketoacidosis. The
client demonstrates an understanding of the teaching by
stating that a form of glucose should be taken if which
symptoms develop? Select all that apply
a) Polyuria
b) Shakiness
c) Palpitations
d) Blurred vision
e) Lightheadedness
f) Fruity breath odor
 Rationale: Shakiness, palpitations, and lightheadedness are
signs of hypoglycemia and would indicate the need for food
or glucose. Polyuria, blurred vision, and a fruity breath odor
are signs of hyperglycemia.
50. A client is admitted to a hospital with a diagnosis of diabetic
ketoacidosis (DKA). The initial blood glucose level was 950
mg/dL. A continuous intravenous infusion of short-acting
insulin is initiated, along with intravenous rehydration with
normal saline. The serum glucose level is now 240 mg/dL.
The nurse would next prepare to administer which item?
a) Ampule of 50% dextrose
b) NPH insulin subcutaneously
c) Intravenous fluids containing dextrose
d) Phenytoin (Dilantin) for the prevention of seizures
Rationale: During management of DKA, when the blood
glucose level falls to 250 to 300 mg/dL, the infusion rate is
reduced and a dextrose solution is added to maintain a
blood glucose level of about 250 mg/dL, or until the client
recovers from ketosis. Fifty percent dextrose is used to treat
hypoglycemia. NPH insulin is not used to treat DKA.
Phenytoin (Dilantin) is not a usual treatment measure for
DKA.
51.
RENAL FAILURE
1. You're preparing for urinary catheterization of a trauma
patient and you observe bleeding at the urethral meatus.
Which action has priority?
a) Irrigate and clean the meatus before
catheterization.
b) Check the discharge for occult blood before
catheterization.
c) Heavily lubricate the catheter before insertion.
d) Delay catheterization and notify the doctor.
Rationale: Bleeding at the urethral meatus is evidence that
the urethra is injured. Because catheterization can cause
further harm, consult with the doctor.
2. Which of the following causes the majority of UTI's in
hospitalized patients?
a) Lack of fluid intake
b) Inadequate perineal care
c) Invasive procedures
d) Immunosuppression
Rationale: Invasive procedures such as catheterization can
introduce bacteria into the urinary tract. A lack of fluid
intake could cause concentration of urine, but wouldn't
necessarily cause infection.
3. A patient with diabetes has had many renal calculi over the
past 20 years and now has chronic renal failure. Which
substance must be reduced in this patient's diet?
a) Carbohydrates
b) Fats
c) Protein
d) Vitamin C
Rationale: Because of damage to the nephrons, the kidney
can't excrete all the metabolic wastes of protein, so this
patient's protein intake must be restricted. A higher intake
of carbs, fats, and vitamin supplements is needed to ensure
the growth and maintenance of the patient's tissues.
4. You're developing a care plan with the nursing diagnosis risk
for infection for your patient that received a kidney
transplant. A goal for this patient is to:
a) Remain afebrile and have negative cultures
b) Resume normal fluid intake within 2 to 3 days
c) Resume the patient's normal job within 2 to 3
weeks
d) Try to discontinue cyclosporine (Neural) as quickly
as possible
Rationale: The immunosuppressive activity of cyclosporine
places the patient at risk for infection, and steroids can
mask the signs of infection. The patient may not be able to
resume normal fluid intake or return to work for an
extended period of time and the patient may need
cyclosporine therapy for life.
5. You suspect kidney transplant rejection when the patient
shows which symptoms?
a) Pain in the incision, general malaise, and
hypotension
b) Pain in the incision, general malaise, and depression
c) Fever, weight gain, and diminished urine output
d) Diminished urine output and hypotension
Rationale: Symptoms of rejection include fever, rapid weight
gain, HTN, pain over the graft site, peripheral edema, and
diminished urine output.
6. Which cause of HTN is the most common in acute renal
failure?
a) Pulmonary edema
b) Hypervolemia
c) Hypovolemia
d) Anemia
Rationale: Acute renal failure causes hypervolemia as a
result of over expansion of extracellular fluid and plasma
volume with the hyper secretion of renin. Therefore,
hypervolemia causes HTN.
7. The most common early sign of kidney disease is:
a) Sodium retention
b) Elevated BUN level
c) Development of metabolic acidosis
d) Inability to dilute or concentrate urine
Rationale: Increased BUN is usually an early indicator of
decreased renal function.
8. Frequent PVCs are noted on the cardiac monitor of a
patient with end-stage renal disease. The priority
intervention is:
a) Call the doctor immediately
b) Give the patient IV lidocaine (Xylocaine)
c) Prepare to defibrillate the patient
d) Check the patient's latest potassium level
Rationale: The patient with ESRD may develop arrhythmias
caused by hypokalemia. Call the doctor after checking the
patient's potassium values. Lidocaine may be ordered if the
PVCs are frequent and the patient is symptomatic.
9. Your patient has complaints of severe right-sided flank pain,
N/V, and restlessness. He appears slightly pale and is
diaphoretic. VS are BP 140/90 mmHg, P 118 bp, RR 33
breaths/min, and T 98.0F. Which subjective data supports a
diagnosis of renal calculi?
a) Pain radiating to the right upper quadrant
b) Hx of mild flu symptoms last week
c) Dark-colored coffee-ground emesis
d) Dark, scanty urine output
Rationale: Patients with renal calculi commonly have blood
in the urine caused by the stone's passage through the
urinary tract. The urine appears dark, tests positive for
blood, and is typically scant.
10. What change indicates recovery in a patient with nephrotic
syndrome?
a) Disappearance of protein from the urine
b) Decrease in BP to normal
 c) Increase in serum lipid levels
d) Gain in body weight
Rationale: With nephrotic syndrome, the glomerular
basement membrane of the kidney becomes more porous,
leading to loss of protein in the urine. As the patient
recovers, less protein is found in the urine.
11. Your 60 y/o patient with pyelonephritis and possible
septicemia has had five UTIs over the past 2 years. She is
fatigued from lack of sleep, has lost weight, and urinates
frequently even in the night. Her labs show: Sodium 154
mEq/L, osmolarity 340 most/L, glucose 127 mg/dl, and
potassium 3.9 mEq/L. Which nursing diagnosis is priority?
a) Fluid volume deficit r/t osmotic diuresis induced by
hyponatremia
b) Fluid volume deficit r/t inability to conserve water
c) Altered nutrition: Less than body requirements r/t
hyper metabolic state
d) Altered nutrition: Less than body requirements r/t
catabolic effects of insulin deficiency
12. Which sign indicates the second phase of acute renal failure
a) Daily doubling of urine output (4 to 5 L/day)
b) Urine output less than 400 mL/day
c) Urine output less than 100 mL/day
d) Stabilization of renal function
Rationale: Daily doubling of the urine output indicates that
the nephrons are healing. This means the patient is passing
into the second phase (diuresis) of acute renal failure.
13. Which drug is indicated for pain r/t acute renal calculi?
a) Narcotic analgesics
b) NSAIDs
c) Muscle relaxants
d) Salicylates
Rationale: Narcotic analgesics are usually needed to relieve
the severe pain of renal calculi. Muscle relaxants are
typically used to treat skeletal muscle spasms. NSAIDs and
salicylate are used for their anti-inflammatory and anti-
pyretic properties and to treat less severe pain.
14. What is the appropriate infusion time for the dialysate in
your 38 y/o patient with chronic renal failure?
a) 15 min
b) 30 min
c) 1 hr.
d) 2 to 3 hrs
Rationale: Dialysate should be infused quickly. The dailysate
should be infused over 15 min or less when performing
peritoneal dialysis. The fluid exchange takes place over a
period ranging from 30 min to several hours
15. A patient returns from surgery with an indwelling urinary
catheter in place and empty. Six hours later, the volume is
120 mL. The drainage system has no obstructions. Which
intervention has priority?
a) Give a 500 mL bolus of isotonic saline
b) Evaluate the patient's circulation and VS
c) Flush the urinary catheter with sterile water or
saline
d) Place the patient in the shock position, and notify
the surgeon
Rationale: A total UO of 120 mL is too low. Assess the
patient's circulation and hemodynamic stability for signs of
hypovolemia. A fluid bolus may be required, but only after
further nursing assessment and a doctor's order.
16. An 18 y/o student is admitted with dark urine, fever, and
flank pain and is diagnosed with acute glomerulonephritis.
Which would most likely be in this student's health history?
a) Renal calculi
b) Renal trauma
c) Recent sore throat
d) Family hx of acute glomerulonephritis
Rationale: The most common form of acute
glomerulonephritis is caused by group A beta-hemolytic
streptococcal infection elsewhere in the body
17. What is the priority nursing diagnosis with your patient
diagnosed with ESRD?
a) Activity intolerance
b) Fluid volume excess
c) Knowledge deficit
d) Pain
Rationale: Fluid volume excess because the kidneys aren't
removing fluid and waste. The other diagnoses may apply,
but they don't take priority.
18. A 22 y/o patient with diabetic nephropathy says, "I have
two kidneys and I'm still young. If I stick to my insulin
schedule, I don't have to worry about kidney damage,
right?" Which of the following statements is the best
response?
a) "You have little to worry about as long as your
kidneys keep making urine."
b) "You should talk to your doctor because statistics
show that you're being unrealistic."
c) "You would be correct if your diabetes could be
managed with insulin."
d) "Even with insulin, kidney damage is still a
concern."
Rationale: Microvascular changes occur in both of the
patient's kidneys as a complication of the diabetes. Diabetic
nephropathy is the leading cause of ESRD. The kidneys
continue to produce urine until the end stage. Nephropathy
occurs even with insulin management.
19. You have a patient that might have a urinary tract infection
(UTI). Which statement by the patient suggests that a UTI is
likely?
a) "I pee a lot."
b) "It burns when I pee."
c) "I go hours without the urge to pee."
d) "My pee smells sweet."
Rationale: A common symptom of a UTI is dysuria. A patient
with a UTI often reports frequent voiding of small amounts
and the urgency to void. Urine that smells sweet is often
associated with DKA.
20. Your patient returns from the operating room after
abdominal aortic aneurysm repair. Which symptom is a sign
of acute renal failure?
a) Anuria
b) Diarrhea
c) Oliguria
d) Vomiting
Rationale: Urine output less than 50 mL in 24 hrs signifies
oliguria, an early sign of renal failure. Anuria is uncommon
except in obstructive renal disorders.
21. Which finding leads you to suspect acute
glomerulonephritis in your 32 y/o patient?
a) Dysuria, frequency, and urgency
b) Back pain, N/V
c) HTN, oliguria, and fatigue
d) Fever, chills, and right upper quadrant pain
radiating to the back
Rationale: Mild to moderate HTN may result from sodium or
water retention and inappropriate renin release from the
 kidneys. Oliguria and fatigue also may be seen. Other signs b) Increase dietary purines potassium back into the cells by administering 50% glucose
are proteinuria and azotemia. c) Restrict fluids and regular insulin, usually in conjunction with some type of
22. Which action is most important during bladder training in a d) Strain all urine base to correct the acidosis, such as sodium bicarbonate or
patient with a neurogenic bladder? Rationale: All urine should be strained through gauze or a calcium gluconate given IV. Insulin assists in the movement
a) Encourage the use of an indwelling urinary catheter urine strainer to catch stones that are passed. The stones of potassium into the cells and helps to reduce the serum
b) Set up specific times to empty the bladder are then analyzed for composition. Ambulation may help the potassium level. Amphojel is used for the treatment of
c) Encourage Kegel exercises movement of the stone down the urinary tract. Encourage hyperphosphatemia that occurs with ARF. Procrit is used for
d) Force fluids fluid to help flush the stones out. the treatment of anemia caused by a decrease in
Rationale: Instruct the patient with neurogenic bladder to 27. Which statement correctly distinguishes renal failure from erythropoietin production by the kidneys. A diuretic, such as
write down his voiding pattern and empty the bladder at the prerenal failure? Lasix, may lead to a loss of potassium, but the rate is too
same times each day. a) With prerenal failure, vasoactive substances such as slow.
23. Clinical manifestations of acute glomerulonephritis include dopamine (Intropin) increase BP 30. A client with chronic renal failure has been prescribed
which of the following? b) With prerenal failure, there is less response to such calcium carbonate. What is the rationale for this particular
a) Chills and flank pain diuretics as furosemide (Lasix) medication?
b) Oliguria and generalized edema c) With prerenal failure, an IV isotonic saline infusion a) Diminishes incidence of gastric ulcer formation
c) Hematuria and proteinuria increases urine output b) Alleviates constipation
d) Dysuria and hypotension d) With prerenal failure, hemodialysis reduces the c) Binds with phosphorus to lower concentration
Rationale: Hematuria and proteinuria indicate acute BUN level d) Increase tubular reabsorption of sodium
glomerulonephritis. These findings result from increased Rationale: Prerenal failure is caused by such conditions as Rationale: Clients with ARF have hyperphosphatemia.
permeability of the glomerular membrane due to the hypovolemia that impairs kidney perfusion; giving isotonic Clients are prescribed calcium-based phosphate binders to
antigen-antibody reaction. Generalized edema is seen most fluids improves urine output. Vasoactive substances can improve excretion of phosphorus.
often in nephrosis. increase BP in both conditions. 31. A client with chronic renal failure has an internal venous
24. Polystyrene sulfonate (Kayexalate) is used in renal failure 28. Your patient with chronic renal failure reports pruritus. access site for hemodialysis on her left forearm. What
to: Which instruction should you include in this patient's action will the nurse take to protect this access site?
a) Correct acidosis teaching plan? a) Irrigate with heparin and NS q8 hrs
b) Reduce serum phosphate level a) Rub the skin vigorously with a towel b) Apply warm moist packs to the area after
c) Exchange potassium for sodium b) Take frequent baths hemodialysis
d) Prevent constipation from sorbitol use c) Apply alcohol-based emollients to the skin c) Do not use the left arm to take blood pressure
Rationale: In renal failure, patients become hyperkalemic d) Keep fingernails short and clean readings.
because they can't excrete potassium in the urine. Rationale: Calcium-phosphate deposits in the skin may d) Keep the arm elevated above the level of the heart.
Polystyrene sulfonate acts to excrete potassium by pulling cause pruritus. Scratching leads to excoriation and breaks in Rationale: Protect the arm with the functioning shunt. No
potassium into the bowels and exchanging it for sodium. the skin that increase the patient's risk of infection. Keeping blood pressure readings should be taken from that arm, and
25. You expect a patient in the oliguric phase of renal failure to the fingernails short and clean helps reduce the risk of there should be no needle sticks. The access is not irrigated
have a 24 hour urine output less than: infection with Heparin.
a) 200 mL 29. A client with acute renal failure develops sever 32. A patient with acute kidney injury (AKI) has an arterial blood
b) 400 mL hyperkalemia. What would the nurse anticipate to be used pH of 7.30. The nurse will assess the patient for ______
c) 800 mL to treat this imbalance? Answer: rapid respirations.
d) 1000 mL a) Furosemide (Lasix) 33. Which information will be most useful to the nurse in
Rationale: Oliguria is defined as output of less than 400 b) Amphojel (aluminum hydroxide) evaluating improvement in kidney function for a patient
mL/24 hours. c) 50% glucose and regular insulin who is hospitalized with acute kidney injury (AKI)?
26. Which intervention do you plan to include with a patient d) Epoetin (Procrit) Answer: Calculated glomerular filtration rate (GFR)
who has renal calculi? Rationale: Hyperkalemia can develop into an emergency
a) Maintain bed rest situation (Cardia Arrest). It is important to quickly move the
34. Before administering sodium polystyrene sulfonate
(Kayexalate) to a patient with hyperkalemia, the nurse
should assess the _____.
Answer: patient's bowel sounds.
35. When the nurse is taking a history for a patient who is a
possible candidate for a kidney transplant, which
information about the patient indicates that the patient is
not an appropriate candidate for transplantation?
Answer: The patient has metastatic lung cancer.
36. Which data obtained when assessing a patient who had a
kidney transplant 8 years ago and who is receiving the
immunosuppressants tacrolimus (Prograf), cyclosporine
(Sandimmune), and prednisone (Deltasone) will be of most
concern to the nurse?
Answer: There is a non-tender lump in the axilla.
37. Which parameter will be most important for the nurse to
consider when titrating the IV fluid infusion rate
immediately after a patient has had kidney transplantation?
Answer: Urine output
38. Before administration of calcium carbonate (Caltrate) to a
patient with chronic kidney disease (CKD), the nurse should
check the laboratory value for ___________
Answer: serum phosphate.
39. After the insertion of an arteriovenous graft (AVG) in the
right forearm, a patient complains of pain and coldness of
the right fingers. Which action should the nurse take?
Answer: Report the patient's symptoms to the health care
provider.
40. A patient who has acute glomerulonephritis is hospitalized
with acute kidney injury (AKI) and hyperkalemia. Which
information will the nurse obtain to evaluate the
effectiveness of the prescribed calcium gluconate IV?
Answer: Cardiac rhythm
41. Which statement by a patient with stage 5 chronic kidney
disease (CKD) indicates that the nurse's teaching about
management of CKD has been effective?
Answer: "I will measure my urinary output each day to
help calculate the amount I can drink."
42. After noting lengthening QRS intervals in a patient with
acute kidney injury (AKI), which action should the nurse
take first?
Answer: Check the chart for the most recent blood
potassium level.
43. The nurse is caring for a patient who had kidney
transplantation several years ago. Which assessment finding
may indicate that the patient is experiencing adverse effects
to the prescribed corticosteroid?
Answer: Joint pain
44. A patient with chronic kidney disease (CKD) brings all home
medications to the clinic to be reviewed by the nurse.
Which medication being used by the patient indicates that
patient teaching is required?
Answer: Milk of magnesia 30 mL
45. D
46. D
47. D
48. D
49. D
50. D
51. D
52. D
53. D
54. D
55. D
56. d
PERITONEAL VS HEMODIALYSIS
1. Which criterion is required before a patient can be
considered for continuous peritoneal dialysis?
a) The patient must be hemodynamically stable
b) The vascular access must have healed
c) The patient must be in a home setting
d) Hemodialysis must have failed
Rationale: Hemodynamic stability must be established
before continuous peritoneal dialysis can be started.
2. You have a patient that is receiving peritoneal dialysis. What
should you do when you notice the return fluid is slowly
draining?
a) Check for kinks in the outflow tubing
b) Raise the drainage bag above the level of the
abdomen
c) Place the patient in a reverse Trendelenburg
position
d) Ask the patient to cough
Rationale: Tubing problems are a common cause of outflow
difficulties, check the tubing for kinks and ensure that all
clamps are open. Other measures include having the patient
change positions (moving side to side or sitting up), applying
gentle pressure over the abdomen, or having a bowel
movement
3. A patient with ESRD has an arteriovenous fistula in the left
arm for hemodialysis. Which intervention do you include in
his plan of care?
a) Apply pressure to the needle site upon
discontinuing hemodialysis
b) Keep HOB elevated 45 degrees
c) Place the left arm on an arm board for at least 30
min
d) Keep the left arm dry
Rationale: Apply pressure when discontinuing hemodialysis
and after removing the venipuncture needle until all the
bleeding has stopped. Bleeding may continue for 10 min in
some patients.
4. Your patient is complaining of muscle cramps while
undergoing hemodialysis. Which intervention is effective in
relieving muscle cramps
a) Increase the rate of dialysis
b) Infuse normal saline solution
c) Administer a 5% dextrose solution
d) Encourage active ROM exercises
Rationale: Tx includes administering normal saline or
hypertonic normal saline solution because muscle cramps
can occur when the sodium and water are removed too
quickly during dialysis. Reducing the rate of dialysis, not
increasing it, may alleviate muscle cramps.
5. Your patient had surgery to form an arteriovenous fistula
for hemodialysis. Which information is important for
providing care for the patient?
a) The patient shouldn't feel pain during initiation of
dialysis.
b) The patient feels best immediately after the dialysis
tx.
c) Using a stethoscope for auscultating the fistula is
contraindicated.
d) Taking a BP reading on the affected arm can cause
clotting of the fistula.
Rationale: Pressure on the fistula or the extremity can
decrease blood flow and precipitate clotting, so avoid taking
BP on the affected arm.
6. What is the best way to check for patency of the
arteriovenous fistula for hemodialysis?
a) Pinch the fistula and note the speed of filling on
release
b) Use a needle and syringe to aspirate blood from the
fistula
c) Check for capillary refill of the nail beds on that
extremity
d) Palpate the fistula throughout its length to assess
for a thrill
Rationale: The vibration or thrill felt during palpation
ensures that the fistula has the desired turbulent blood flow.
Pinching the fistula could cause damage. Aspirating blood is
a needless invasive procedure.
7. Your patient becomes restless and tells you she has a
headache and feels nauseous during hemodialysis. Which
complication do you suspect?
a) Infection
b) Disequilibrium syndrome
c) Air embolus
d) Acute hemolysis
Rationale: Disequilibrium syndrome is caused by a rapid
reduction in urea, sodium, and other solutes from the blood.
This can lead to cerebral edema and increased ICP. S/S
include headache, nausea, restlessness, vomiting, confusion,
twitching, and seizures.
8. A patient with DM and renal failure begins hemodialysis.
Which diet is best on days between dialysis treatments?
a) Low-protein diet with unlimited amounts of water
b) Low-protein diet with a prescribed amount of
water
c) No protein in the diet and use of a salt substitute
d) No restrictions
Rationale: Patient requires some protein to meet metabolic
needs. Salt substitutes shouldn't be used w/o a Dr's order
b/c it may contain potassium, which could make the patient
hyperkalemic. Fluid and protein restrictions are needed.
9. A 30 y/o female patient is undergoing hemodialysis with an
internal arteriovenous fistula in place. What do you do to
prevent complications associated with this device?
a) Insert IV lines above fistula
b) Avoid taking BPs in the arm with the fistula
c) Palpate pulses above the fistula
d) Report a bruit or thrill over the fistula to the doctor
Rationale: Because the compression could damage the
fistula. IV lines shouldn't be inserted in the arm used for
hemodialysis. Palpate pulses below the fistula. Lack of bruit
or thrill should be reported to the doctor.
10. When a patient who has had progressive chronic kidney
disease (CKD) for several years is started on hemodialysis,
which information about diet will the nurse include in
patient teaching?
Answer: More protein will be allowed because of the
removal of urea and creatinine by dialysis.
11. A patient needing vascular access for hemodialysis asks the
nurse what the differences are between an arteriovenous
(AV) fistula and a graft. The nurse explains that one
advantage of the fistula is that it _______.
Answer: is much less likely to clot.
12. Which action by a patient who is using peritoneal dialysis
(PD) indicates that the nurse should provide more teaching
about PD?
Answer: The patient cleans the catheter while taking a
bath every day.
13. During hemodialysis, a patient complains of nausea and
dizziness. Which action should the nurse take first?
Answer: Check the patient's blood pressure.
14. A patient complains of leg cramps during hemodialysis. The
nurse should first ___________
Answer: infuse a bolus of normal saline.
15. The nurse instructs a client with renal failure who is
receiving hemodialysis about dietary modifications. The
nurse determines that the client understands these dietary
modifications if the client selects which items from the
menu?
a) Cream of wheat, blueberries, coffee
b) Sausage and eggs, banana, orange juice.
c) Bacon, cantaloupe melon, tomato juice.
d) Cured pork, grits, strawberries, orange juice
Rationale: The diet for a client with renal failure who is
receiving hemodialysis should include controlled amounts of
sodium, phosphorus, calcium, potassium, and fluids. Options
2, 3, and 4 are high in sodium, phosphorus and potassium.
16. The client with chronic renal failure is scheduled for
hemodialysis this morning is due to receive a daily dose of
enalapril (Vasotec). The nurse should plan to administer this
medication:
a) During dialysis.
b) Just before dialysis.
c) The day after dialysis.
d) On return from dialysis.
Rationale: Antihypertensive medications such as enalapril
are given to the client following hemodialysis. This prevents
the client from becoming hypotensive during dialysis and
also from having the medication removed from the
bloodstream by dialysis. No rationale exists for waiting an
entire day to resume the medication. This would lead to
ineffective control of the blood pressure.
17. The client being hemodialyzed suddenly becomes short of
breath and complains of chest pain. The client is
tachycardic, pale, and anxious. The nurse suspects air
embolism. The priority action for the nurse is to:
a) Discontinue dialysis and notify the physician.
b) Monitor vital signs every 15 minutes for the next
hour.
c) Continue dialysis at a slower rate after checking the
lines for air.
d) Bolus the client with 500 mL of normal saline to
break up the embolus.
Rationale: If the client experiences air embolus during
hemodialysis, the nurse should terminate dialysis
immediately, notify the physician, and administer oxygen as
needed. Options 2, 3, and 4 are incorrect.
18. The nurse has completed client teaching with the
hemodialysis client about self-monitoring between
hemodialysis treatments. The nurse determines that the
client best understands the information if the client states
to record daily the:
a) Amount of activity.
b) Pulse and respiratory rate.
c) Intake and output and weight.
d) Blood urea nitrogen and creatinine levels
Rationale: The client on hemodialysis should monitor fluid
status between hemodialysis treatments by recording intake
and output and measuring weight daily. Ideally, the
hemodialysis client should not gain more than 0.5 kg of
weight/day.
19. The client with an external arteriovenous shunt in place for
hemodialysis is at risk for bleeding. The priority nurse action
would be to:
a) Check the shunt for the presence of bruit and thrill.
b) Observe the site once as time permits during the
shift.
c) Check the results of the prothrombin times as they
are determined.
d) Ensure that small clamps are attached to the
arteriovenous shunt dressing.
Rationale: An arteriovenous shunt is a less common form of
access site but carries a risk for bleeding when it is used
because two ends of an external cannula are tunneled
subcutaneously into an artery and a vein, and the ends of
the cannula are joined. If accidental disconnection occurs,
the client could lose blood rapidly. For this reason, small
clamps are attached to the dressing that covers the insertion
site for use if needed. The shunt site also should be assessed
at least every 4 hours.
20. A nurse is assessing the patency of a client's left arm
arteriovenous fistula prior to initiating hemodialysis. Which
finding indicates that the fistula is patent?
a) Palpation of a thrill over the fistula.
b) Presence of a radial pulse in the left wrist.
c) Absence of a bruit on auscultation of the fistula.
d) Capillary refill less than 3 seconds in the nail beds of
the fingers of the left hand.
Rationale: The nurse assesses the patency of the fistula by
palpating for the presence of a thrill or auscultating for a
bruit. The presence of a thrill and bruit indicate patency of
the fistula. Although the presence of a radial pulse in the left
wrist and capillary refill shorter than 3 seconds in the nail
beds of the fingers on the left hand are normal findings, they
do not assess fistula patency.
21. The client newly diagnosed with chronic renal failure
recently has begun hemodialysis. Knowing that the client is
at risk for disequilibrium syndrome, the nurse assesses the
client during dialysis for:
a) Hypertension, tachycardia, and fever.
b) Hypotension, bradycardia, and hypothermia.
c) Restlessness, irritability, and generalized weakness.
d) Headache, deteriorating level of consciousness,
and twitching.
Rationale: Disequilibrium syndrome is characterized by
headache, mental confusion, decreasing level of
consciousness, nausea, vomiting, twitching, and possible
seizure activity. Disequilibrium syndrome is caused by rapid
removal of solutes from the body during hemodialysis. At
the same time, the blood-brain barrier interferes with the
efficient removal of wastes from brain tissue. As a result,
water goes into cerebral cells because of the osmotic
gradient, causing brain swelling and onset of symptoms. The
syndrome most often occurs in clients who are new to
dialysis and is prevented by dialyzing for shorter times or at
reduced blood flow rates.
22. A client with chronic renal failure has completed a
hemodialysis treatment. The nurse would use which of the
following standard indicators to evaluate the client's status
after dialysis?
a) Vital signs and weight.
b) Potassium level and weight.
c) Vital signs and BUN.
d) BUN and creatinine levels.
Rationale: Following dialysis, the client's vital signs are
monitored to determine whether the client is remaining
hemodynamically stable. Weight is measured and compared
with the client's pre-dialysis weight to determine
effectiveness of fluid extraction. Laboratory studies are done
as per protocol but are not necessarily done after the
hemodialysis treatment has ended.
23. The hemodialysis client with a left arm fistula is at risk for
arterial steal syndrome. The nurse assesses this client for
which of the following manifestations?
a) Warmth, redness, and pain in the left hand.
b) Pallor, diminished pulse, and pain in the left hand.
c) Edema and reddish discoloration of the left arm.
d) Aching pain, pallor, and edema of the left arm.
Rationale: Steal syndrome results from vascular insufficiency
after creation of a fistula. The client exhibits pallor and a
diminished pulse distal to the fistula. The client also
complains of pain distal to the fistula, caused by tissue
ischemia. Warmth, redness, and pain probably would
characterize a problem with infection. The manifestations
described in options 3 and 4 are incorrect.
24. The client with chronic renal failure returns to the nursing
unit following a hemodialysis treatment. On assessment,
the nurse notes that the client's temperature is 100.2F.
Which of the following is the appropriate nursing action?
a) Encourage fluids.
b) Notify the physician.
c) Continue to monitor vital signs.
d) Monitor the site of the shunt for infection.
Rationale: The client may have an elevated temperature
following dialysis because the dialysis machine warms the
blood slightly. If the temperature is elevated excessively and
remains elevated, sepsis would be suspected and a blood
sample would be obtained as prescribed for culture and
sensitivity determinations.
25. The nurse is performing an assessment on a client who has
returned from the dialysis unit following hemodialysis. The
client is complaining of headache and nausea and is
extremely restless. Which of the following is the most
appropriate nursing action?
a) Monitor the client.
b) Notify the physician.
c) Elevate the head of the bed.
d) Medicate the client for nausea.
Rationale: Disequilibrium syndrome may be caused by the
rapid decreases in the blood urea nitrogen level during
hemodialysis. These changes can cause cerebral edema that
leads to increased intracranial pressure. The client is
exhibiting early signs of disequilibrium syndrome and
appropriate treatments with anticonvulsive medications and
barbiturates may be necessary to prevent a life-threatening
situation. The physician must be notified.
26. A nurse is analyzing the post hemodialysis lab test results
for a client with chronic renal failure (CRF). The nurse
interprets that the dialysis is having an expected but
nontherapeutic effect if the results indicate a decreased:
a) Phosphorus.
b) Creatinine.
c) Potassium.
d) Red blood cell count
Rationale: Hemodialysis typically lowers the amounts of
fluid, sodium, potassium, urea nitrogen, creatinine, uric acid,
magnesium, and phosphate levels in the blood.
Hemodialysis also worsens anemia, because RBCs are lost in
dialysis from blood sampling and anticoagulation during the
procedure, and from residual blood that is left in the
 dialyzer. Although all of these results are expected, only the
lowered RBC count is nontherapeutic and worsens the
anemia already caused by the disease process.
27. A client diagnosed with chronic renal failure (CRF) is
scheduled to begin hemodialysis. The nurse assesses that
which of the following neurological and psychosocial
manifestations if exhibited by this client would be unrelated
to the CRF?
a) Labile emotions.
b) Withdrawal.
c) Euphoria.
d) Depression.
Rationale: The client with CRF often experiences a variety of
psychosocial changes. These are related to uremia, as well
as the stress associated with living with a chronic disease
that is life-threatening. Clients with CRF may have labile
emotions or personality changes and may exhibit
withdrawal, depression, or agitation. Delusions and
psychosis also can occur. Euphoria is not part of the clinical
picture for the client in renal failure.
28. A nurse is working with the client newly diagnosed with
chronic renal failure (CRF) to set up a schedule for
hemodialysis. The client states, "This is impossible! How can
I even think about leading a normal life again if this is what
I'm going to have to do?" The nurse assesses that the client
is exhibiting:
a) Withdrawal
b) Depression
c) Anger
d) Projection
Rationale: Psychosocial reactions to CRF and hemodialysis
are varied and may include anger. Other reactions include
personality changes, emotional lability, withdrawal, and
depression. The individual client's response may vary
depending on the client's personality and support systems.
The client in this question is exhibiting anger. The client has
not projected blame on the nurse, nor does the client
statement reflect withdrawal or depression.
29. A nurse is giving general instructions to a client receiving
hemodialysis. Which of the following statements would be
appropriate for the nurse to include?
a) Several types of medications should be withheld
on the day of dialysis until after the procedure.
b) Medications should be double-dosed on the
morning of hemodialysis to prevent loss.
c) It's acceptable to exceed the fluid restriction on the
day before hemodialysis.
d) It's acceptable to eat whatever you want on the day
before hemodialysis.
Rationale: Many medications are dialyzable, which means
they are extracted from the bloodstream during dialysis.
Therefore, many medications may be withheld on the day of
dialysis until after the procedure. It is not typical for
medications to be "double-dosed," because there is no way
to be certain how much of each medication is cleared by
dialysis. Clients receiving hemodialysis are not routinely
taught that it is acceptable to disregard dietary and fluid
restrictions.
30. A client undergoing hemodialysis is at risk for bleeding from
the heparin used during the hemodialysis treatment. The
nurse assesses for this occurrence by periodically checking
the results of which of the following lab tests?
a) Partial thromboplastin time (PTT)
b) Prothrombin time (PT)
c) Thrombin time (TT)
d) Bleeding time
Rationale: Heparin is the anticoagulant used most often
during hemodialysis. The hemodialysis nurse monitors the
extent of anticoagulation by checking the PTT, which is the
appropriate measure of heparin effect. The PT is used to
monitor the effect of warfarin (Coumadin) therapy.
Thrombin and bleeding times are not used to measure the
effect of heparin therapy, although they are useful in the
diagnosis of other clotting abnormalities.
31. A registered nurse is instructing a new nursing graduate
about hemodialysis. Which statement if made by the new
nursing graduate would indicate an inaccurate
understanding of the procedure for hemodialysis?
a) Sterile dialysate must be used.
b) Warming the dialysate increases the efficiency of
diffusion.
c) Heparin sodium is administered during dialysis.
d) Dialysis cleanses the blood from accumulated waste
products.
Rationale: Dialysate is made from clear water and chemicals
and is free from any metabolic waste products or
medications. Bacteria and other microorganisms are too
large to pass through the membrane; therefore, the
dialysate does not need to be sterile. The dialysate is
warmed to approximately 100° F to increase the efficiency
of diffusion and to prevent a decrease in the client's blood
temperature. Heparin sodium inhibits the tendency of blood
to clot when it comes in contact with foreign substances.
Option 4 is the purpose of dialysis.
32. A client with chronic renal failure is about to begin
hemodialysis therapy. The client asks the nurse about the
frequency and scheduling of hemodialysis treatments. The
nurse's response is based on an understanding that the
typical schedule is:
a) 5 hours of treatment 2 days per week.
b) 3 to 4 hours of treatment 3 days per week
c) 2 to 3 hours of treatment 5 days per week
d) 2 hours of treatment 6 days per week
Rationale: The typical schedule for hemodialysis is 3 to 4
hours of treatment three days per week. Individual
adjustments may be made according to variables such as
the size of the client, type of dialyzer, the rate of blood flow,
personal client preferences, and others.
33. The nurse has instructed a patient who is receiving
hemodialysis about dietary management. Which diet
choices by the patient indicate that the teaching has been
successful?
a) Scrambled eggs, English muffin, and apple juice
b) Cheese sandwich, tomato soup, and cranberry juice
c) Split-pea soup, whole-wheat toast, and nonfat milk
d) Oatmeal with cream, half a banana, and herbal tea
Rationale: Scrambled eggs would provide high-quality
protein, and apple juice is low in potassium. Cheese is high
in salt and phosphate, and tomato soup would be high in
potassium. Split-pea soup is high in potassium, and dairy
products are high in phosphate. Bananas are high in
potassium, and the cream would be high in phosphate.
34. A patient begins hemodialysis after having had conservative
management of chronic kidney disease. The nurse explains
that one dietary regulation that will be changed when
hemodialysis is started is that
a) Unlimited fluids are allowed since retained fluid is
removed during dialysis.
 b) Increased calories are needed because glucose is
lost during hemodialysis.
c) More protein will be allowed because of the
removal of urea and creatinine by dialysis.
d) Dietary sodium and potassium are unrestricted
because these levels are normalized by dialysis.
Rationale: Once the patient is started on dialysis and
nitrogenous wastes are removed, more protein in the diet is
allowed. Fluids are still restricted to avoid excessive weight
gain and complications such as shortness of breath. Glucose
is not lost during hemodialysis. Sodium and potassium
intake continues to be restricted to avoid the complications
associated with high levels of these electrolytes.
35. A patient with chronic kidney disease (CKD) is started on
hemodialysis, and after the first treatment, the patient
complains of nausea and a headache. The nurse notes mild
jerking and twitching of the patient's extremities. The nurse
will anticipate the need to
a) Increase the time for the next dialysis to remove
wastes more completely.
b) Switch to continuous renal replacement therapy
(CRRT) to improve dialysis efficiency.
c) Administer medications to control these symptoms
before the next dialysis.
d) Slow the rate for the next dialysis to decrease the
speed of solute removal.
Rationale: he patient has symptoms of disequilibrium
syndrome, which can be prevented by slowing the rate of
dialysis so that fewer solutes are removed during the
dialysis. Increasing the time of the dialysis to remove wastes
more completely will increase the risk for disequilibrium
syndrome. CRRT is a less efficient means of removing wastes
and, because it is continuous, would not be used for a
patient with CKD. Administration of medications to control
the symptoms is not an appropriate action; rather, the
disequilibrium syndrome should be avoided.
36. A patient with acute renal failure (ARF) requires
hemodialysis and temporary vascular access is obtained by
placing a catheter in the left femoral vein. The nurse will
plan to
a) Restrict the patient's oral protein intake.
b) Discontinue the retention catheter.
c) Place the patient on bed rest.
d) Start continuous pulse oximetry.
Rationale: The patient with a femoral vein catheter must be
on bed rest to prevent trauma to the vein. Protein intake is
likely to be increased when the patient is receiving dialysis.
The retention catheter is likely to remain in place because
accurate measurement of output will be needed. There is no
indication that the patient needs continuous pulse oximetry.
37. A client has an arteriovenous (AV) fistula in place in the
right upper extremity for hemodialysis treatments. When
planning care for this client, which of the following
measures should the nurse implement to promote client
safely?
a) Take blood pressures only on the right arm to
ensure accuracy
b) Use the fistula for all venipunctures and intravenous
infusions
c) Ensure that small clamps are attached to the AV
fistula dressing
d) Assess the fistula for the presence of a bruit and
thrill every 4 hours
38. The client with chronic renal failure who is scheduled for
hemodialysis this morning is due to receive a daily dose of
enalapril (Vasotec). The nurse should plan to administer this
medication:
a) During dialysis
b) Just before dialysis
c) The day after dialysis
d) On return form dialysis
39. The client with chronic renal failure is on chronic
hemodialysis. Which of the following indicate improvement
of the client's condition due to hemodialysis? Select all that
apply
a) The client's BP is 130/90
b) The client's serum potassium is 4.8 mEq/L
c) The client's hemoglobin level is 10 g/dL
d) The client's serum calcium is 7.7 mg/dL
e) The client's serum sodium is 140 mEg/L
f) The client's serum magnesium is 4 mEq/L
g) The client's weight has increased from 60 kg to 63
kg
40. The client had been diagnosed to have chronic renal failure.
He had undergone hemodialysis for the first time. What
signs and symptoms when experienced by the client suggest
that he is experiencing disequilibrium syndrome?
a) Restlessness, hypotension, headache
b) Nausea and vomiting, hypertension, dizziness
c) Lethargy, hypotension, dizziness
d) Tachycardia, hypotension, headache
Rationale: Nausea and vomiting, hypertension, dizziness
disequilibrium syndrome is caused by more rapid
removal of waste products from the blood from the
brain. This is due to the presence of blood-brain barrier.
This causes increased intracranial pressure
41. The client with chronic renal failure has an indwelling
abdominal catheter for peritoneal dialysis. The client spills
water on the catheter dressing while bathing. The nurse
should immediately:
a) Change the dressing
b) Reinforce the dressing
c) Flush the peritoneal dialysis catheter
d) Scrub the catheter with povidine-iodine
Rationale: Clients with peritoneal dialysis catheters are at
high risk for infection. A wet dressing is a conduit for
bacteria to reach the catheter insertion site. The nurse
ensures that the dressing is kept dry at all times. Reinforcing
the dressing is not a safe practice to prevent infection in this
circumstance. Flushing the catheter is not indicated.
Scrubbing the catheter with povidone-iodine is done at the
time of connection or disconnection of peritoneal dialysis.
42. The client with continuous ambulatory peritoneal dialysis
(CAPD) has cloudy dialysate. Which of the following is the
best initial nursing action?
a) Send fluid to the laboratory for culture
b) Administer antibiotic
c) Do nothing, this is expected
d) Stop drainage of fluid
Rationale: Cloudy dialysate indicates infection (peritonitis).
Culture of the fluid must be done to determine the
microorganism present.
43. Which of the following client responses shows a correct
understanding of continuous ambulatory peritoneal dialysis
(CAPD)?
a) I am expected to perform the procedure at home
b) The procedure lasts for one hour
c) I have to sit and raise my legs during the procedure
 d) I have to go to the hospital for this procedure
44. The client with chronic renal failure is undergoing peritoneal
dialysis. He asks why the nurse monitors his blood glucose
levels. Which of the following will be the most appropriate
response by the nurse?
a) I have to check if you have diabetes mellitus
b) The dialysate contains glucose
c) The procedure may lower your blood glucose levels
d) It is a routine procedure for every client who
undergoes the treatment
45. A client with end-stage renal disease is receiving continuous
ambulatory peritoneal dialysis. The nurse is monitoring the
client for signs of complications associated with peritoneal
dialysis. Select all that apply.
a) Pruritus
b) Oliguria
c) Tachycardia
d) Cloudy outflow
e) Abdominal pain
Rationale: Tachycardia can be caused by peritonitis, a
complication of peritoneal dialysis; the heart rate increases
to meet the metabolic demands associated with infection.
Cloudy or opaque dialysate outflow (effluent) is the earliest
sign of peritonitis; it is caused by the constituents associated
with an infectious process. Abdominal pain is associated
with peritonitis, a complication of peritoneal dialysis; pain
results from peritoneal inflammation, abdominal distention,
and involuntary muscle spasms. Severe itching (pruritus) is
caused by metabolic waste products that are deposited in
the skin; dialysis removes metabolic waste products,
preventing this adaptation associated with kidney failure.
The production of abnormally small amounts of urine
(oliguria) is a sign of kidney failure, not a complication of
peritoneal dialysis.
46. The nurse is reviewing the list of components contained in
the peritoneal dialysis solution with the client. The client
asks the nurse about the purpose of the glucose contained
in the solution. The nurse bases the response on knowing
that the glucose:
a) Decreases the risk of peritonitis.
b) Prevents disequilibrium syndrome.
c) Increases osmotic pressure to produce
ultrafiltration.
d) Prevents excess glucose from being removed from
the client.
Rationale: Increasing the glucose concentration makes the
solution more hypertonic. The more hypertonic the solution,
the higher the osmotic pressure for ultrafiltration and thus
the greater the amount of fluid removed from the client
during an exchange. Options 1, 2, and 4 do not identify the
purpose of the glucose.
47. The nurse is preparing to care for a client receiving
peritoneal dialysis. Which of the following would be
included in the nursing plan of care to prevent the major
complication associated with peritoneal dialysis?
a) Maintain strict aseptic technique.
b) Add heparin to the dialysate solution.
c) Change the catheter site dressing daily.
d) Monitor the client's level of consciousness.
Rationale: The major complication of peritoneal dialysis is
peritonitis. Strict aseptic technique is required in caring for
the client receiving this treatment. Although option 3 may
assist in preventing infection, this option relates to an
external site. Options 2 and 4 are unrelated to the major
complication of peritoneal dialysis.
48. A client newly diagnosed with renal failure has just been
started on peritoneal dialysis. During the infusion of the
dialysate, the client complains of abdominal pain. Which
action by the nurse is appropriate?
a) Stop the dialysis.
b) Slow the infusion.
c) Decrease the amount to be infused.
d) Explain that the pain will subside after the first few
exchanges.
Rationale: Pain during the inflow of dialysate is common
during the first few exchanges because of peritoneal
irritation; however, the pain usually disappears after 1 to 2
weeks of treatment. The infusion amount should not be
decreased, and the infusion should not be slowed or stopped
49. The nurse is instructing a client with diabetes mellitus about
peritoneal dialysis. The nurse tells the client that it is
important to maintain the prescribed dwell time for the
dialysis because of the risk of:
a) Infection.
b) Hyperglycemia.
c) Hypophosphatemia.
d) Disequilibrium syndrome.
Rationale: An extended dwell time increases the risk of
hyperglycemia in the client with diabetes mellitus as a result
of absorption of glucose from the dialysate and electrolyte
changes. Diabetic clients may require extra insulin when
receiving peritoneal dialysis.
50. The nurse monitoring a client receiving peritoneal dialysis
notes that the client's outflow is less than the inflow. Select
all nursing actions in the situation that apply.
a) Contact the physician.
b) Check the level of the drainage bag.
c) Reposition the client to his or her side.
d) Place the client in good body alignment.
e) Check the peritoneal dialysis system for kinks.
f) Increase the flow rate of the peritoneal dialysis
solution.
Rationale: If outflow drainage is inadequate, the nurse
attempts to stimulate outflow by changing the client's
position. Turning the client to the other side or making sure
that the client is in good body alignment may assist with
outflow drainage. The drainage bag needs to be lower than
the client's abdomen to enhance gravity drainage. The
connecting tubing and peritoneal dialysis system are also
checked for kinks or twisting and the clamps on the system
are checked to ensure that they are open. There is no reason
to contact the physician. Increasing the flow rate is an
inappropriate action and is not associated with the amount
of outflow solution.
51. A nurse instructs a client about continuous ambulatory
peritoneal dialysis (CAPD). Which of the following
statements if made by the client indicates an accurate
understanding of CAPD?
a) A portable hemodialysis machine is used so that I
will be able to ambulate during the treatment.
b) A cycling machine is used so the risk for infection is
minimized.
c) No machinery is involved, and I can pursue my
usual activities.
d) The drainage system can be used once during the
day and a cycling machine for 3 cycles at night.
Rationale: CAPD closely approximates normal renal
function, and the client will need to infuse and drain the
 dialysis solution several times a day. No machinery is used, c) "The infusion clamp should be open during
and CAPD is a manual procedure. infusion."
52. A patient with diabetes who has chronic kidney disease d) "It is appropriate to warm the dialysate in a
(CKD) is considering using continuous ambulatory peritoneal microwave."
dialysis (CAPD). In discussing this treatment option with the Rationale: The dialysate should be warmed in a commercial
patient, the nurse informs the patient that warmer and never in a microwave oven. Strict aseptic
a) Patients with diabetes who use CAPD have fewer technique is essential. The infusion clamp is opened during
dialysis-related complications than those on the infusion and clamped after the infusion. When the dwell
hemodialysis. time is done, the drain clamp is opened and the fluid is
b) Home CAPD requires more extensive equipment allowed to drain by gravity into the drainage bag.
than does home hemodialysis.
c) CAPD is contraindicated for patients who might acute inferior wall MI with complete AV block,
eventually want a kidney transplant. Acute Liver Failure
d) Dietary restrictions are stricter for patients using
CAPD than for those having hemodialysis
Rationale: Patients with diabetes have better control of
blood pressure, less hemodynamic instability, and fewer
problems with retinal hemorrhages when using peritoneal
dialysis than when using hemodialysis. CAPD is less
expensive and has fewer dietary restrictions than
hemodialysis. CAPD is not a contraindication for a kidney
transplant.
53. A patient who has been on continuous ambulatory
peritoneal dialysis (CAPD) is hospitalized and is receiving
CAPD with four exchanges a day. During the dialysate
inflow, the patient complains of having abdominal pain and
pain in the right shoulder. The nurse should
a) Massage the patient's abdomen and back.
b) Decrease the rate of dialysate infusion.
c) Stop the infusion and notify the health care
provider.
d) Administer the PRN acetaminophen (Tylenol).
Rationale: Abdominal pain and referred shoulder pain can
be caused by a rapid infusion of dialysate; the nurse should
slow the rate of the infusion. Massage and administration of
acetaminophen (Tylenol) would not address the reason for
the pain. There is no need to notify the health care provider.
54. After teaching a group of students about how to perform
peritoneal dialysis, which statement would indicate to the
instructor that the students need additional teaching?
a) "The effluent should be allowed to drain by gravity."
b) "It is important to use strict aseptic technique."