MEMBERS:

CULTURA CAMILLE
DE LEON JOSE PAOLO
SANAANI NUR-FATIMA
MIGUEL KATE ANGELIE
KAMDON, Mohammad YUSUF
NURCO-2(SEC-H)

29. A male adult client admitted with a gunshot wound to the abdomen is transferred to the
intensive care unit after an exploratory laparotomy. Which assessment finding suggests that the
client is experiencing acute renal failure (ARF)?

A. Blood urea nitrogen (BUN) level of 22 mg/dl

B. Serum creatinine level of 1.2 mg/dl

C. Serum creatinine level of 1.2 mg/dl

D. Urine output of 400 ml/24 hours

RATIONALE: Acute kidney injury, previously known as acute renal failure, denotes a sudden
and often reversible reduction in the kidney function, as measured by increased creatinine or
decreased urine volume.

30. Nurse Bonnie is providing dietary instruction to a male client who has been treated for
chronic renal failure (CRF). Which of the following statements indicate that the teaching has
been effective?

A. "I must eat meat at every meal."

B. "I should mmonitor my fruit intake, and eat plenty of bananas."

C. "I must increase my carbohydrate intake."

D. "I should drink plenty of fluids, and use a salt substitute."

RATIONALE: Extra carbohydrates are needed to prevent protein catabolism. In a client with
CRF, unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous
accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia.
Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which
are high in potassium; and fluid, because the failing kidneys can't secrete adequate urine. Salt
substitutes are high in potassium and should be avoided.
31. The evening nurse reviews the nursing documentation in the male client's chart and notes
that the day nurse has documented that the client has a stage II pressure ulcer in the sacral
area. Which of the Following would the nurse expect to note on assessment of the client's sacral
area?

A. Intact skin

B. Full-thickness skin loss

C. Exposed bone, tendon, or muscle

D. Partial-thickness skin loss of the dermis

RATIONALE: In stage II pressure ulcer, the skin is not intact. It presents as a shallow open ulcer
with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured,
serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III.
Exposed bone,tendon, or muscle is present in stage IV.

32 A male client arrives at the emergency room and has experienced frostbites to the right
hand. Which of the following would the nurse note on assessment of the client's hand?

A. A pink, edematous hand

B. A fiery red skin with edema in the nail beds

C. Black fingertips surrounded by an erythematous rash

D. A white color to the skin, which is insensitive to touch

RATIONALE: Frostbite findings include white and blue discoloration of the skin. The skin will
also be hard, cold and insensitive to touch. As thawing occurs, flushing of the skin, the
development of blisters or blebs, or tissue edema appears.

33. Which of the following nursing interventions is appropriate for a client who underwent a

transurethral resection of the prostate gland 24 hours ago and is on continuous bladder
irrigation?

A. Tell the client to try to urinate around the catheter to remove blood clots.

B. Restrict fluids to prevent the client's bladder from becoming distended.

C. Prepare to remove the catheter.

D. Use aseptic technique when irrigating the catheter

RATIONALE: Aseptic technique is the first thing to do when irrigating in order to prevent the
client from infection.

34. The nurse is reviewing the laboratory result of a male client with chronic renal failure and
noted serum potassium level of 6.8 mEq/L. What should nurse Olivia assess first?

A. Blood pressure

B. Respirations

C. Temperature

D. Pulse

RATIONALE: An elevated serum potassium level may lead to a life-threatening cardiac

arrhythmia, which the nurse can detect immediately by palpating the pulse. The client's blood
pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should
assess blood pressure later. The nurse also can delay assessing respirations and temperature
because these aren't affected by the serum potassium level.

35. After inserting an indwelling Foley catheter, the nurse begins to inflate the balloon and the
client complains of pain. Which of the following would be the priority action for the nurse to
implement?

A. Aspirate back solution from the balloon and remove the catheter

B. Insert the remainder of the solution in the balloon and pull back gently until resistance is felt

C. Aspirate back solution from the balloon and advance the catheter further

D. Withdraw the catheter slightly and insert an additional 1 ml into the balloon."

RATIONALE: To prevent dislodging the thrombus from the reperfusion catheter as it is

withdrawn into the guide catheter