NR-325 Adult Health II - Set 2 - Part 1

Correct Answer: Apply oxygen and stay with the client

Frothy sputum with crackles high in the lung fields is acute pulmonary edema, a breathing emergency. Oxygen and the nurse's presence come before any laboratory value, following the airway and breathing rule. Option b is incorrect because a repeat draw yields a number, not relief, and the reported level sits below the range that stops a heart. Oxygenation is failing right now at the bedside. Option c is incorrect because tracing the rhythm answers a cardiac question while the lungs are drowning. The test also pulls the nurse into equipment setup instead of immediate respiratory support. Option d is incorrect because daily weight documents fluid gain over time and guides later treatment decisions. Moving a breathless client onto a scale during respiratory distress wastes minutes that matter enormously.

Correct Answer: Have sore throats cultured and fully treated

Culturing a sore throat and completing the whole course of penicillin removes the nephritogenic strep before immune complexes can form. Stopping the trigger is the single most effective prevention measure available. Option a is incorrect because year round prophylaxis is not the standard for this condition and would breed resistant organisms. Antibiotics are given for an active streptococcal infection, not indefinitely afterward. Option b is incorrect because total avoidance of other people is neither practical nor necessary. Reasonable hand hygiene helps, but the decisive step is treating a strep infection properly once it does occur. Option d is incorrect because protein is moderated only while blood urea nitrogen stays high, then liberalized as function returns. Permanent restriction risks malnutrition and does nothing to stop a future strep infection.

Correct Answer: The client's weight on arrival

The gap between the arrival weight and the dry weight tells the machine how much to remove, since roughly one kilogram of body weight equals one liter of fluid. Weights are taken both before and after the session. Option b is incorrect because temperature screens for infection and does not quantify volume. A fever in a dialysis client prompts blood cultures before the session, but it tells nobody how many liters to pull off. Option c is incorrect because recall of drinks over three days is unreliable and misses fluid in food. Scales measure what actually stayed in the body, which is why the pre-treatment weight governs the prescription. Option d is incorrect because hemoglobin tracks whether the erythropoiesis stimulating agent is working. It guides anemia management across weeks and has no bearing on how much water comes off during this afternoon's treatment.

Correct Answer: "I will wear my watch on the other wrist now."

Anything that constricts the limb can occlude flow and clot the fistula, so watches, tight sleeves and jewelry move to the other arm. The client also refuses blood pressure readings and needle sticks there. Option a is incorrect because lying on the fistula arm applies sustained pressure through the night, long enough for flow to stall and a clot to form. Warmth is not the issue; sustained compression is what closes the access. Option b is incorrect because a tight sleeve acts like a tourniquet over the anastomosis rather than a support. Fistulas need unrestricted outflow, and steady external pressure is one of the common causes of thrombosis. Option d is incorrect because venipuncture damages the arterialized vein the fistula depends on and seeds bacteria into the access. Healing of the incision never lifts that restriction; the ban lasts as long as the fistula does.

Correct Answer: Diabetes with stool incontinence and immobility

Diabetes, stool incontinence and immobility are the classic clustered risks. Sugar in the urine feeds organisms, soiled perineal skin delivers them to the meatus, and immobility leaves urine standing long enough to multiply. Option a is incorrect because mobility and good hydration are protective rather than harmful. Walking promotes complete emptying and dilute urine flushes the tract, so this resident sits at the low end of risk. Option b is incorrect because immunization against influenza and joint pain have no bearing on bladder colonization. Neither factor obstructs flow, breaches a barrier or contaminates the perineum, which is what actually drives risk. Option c is incorrect because reduced hearing affects communication, not urine flow, and a sodium limit is a cardiac or renal measure. Neither one changes the defenses that keep organisms out of the bladder.

Correct Answer: Chicken breast with green beans and applesauce

Chicken, green beans and applesauce all sit on the low potassium list, so this tray keeps the load down. Choosing it shows the client can apply the restriction to a real menu. Option a is incorrect because potatoes and milk are two of the heaviest potassium sources on any hospital tray. Pairing them would push the serum level toward dangerous territory within a day. Option b is incorrect because tomatoes and orange juice both carry substantial potassium, and the juice adds unwanted fluid as well. The sandwich itself is acceptable, yet the accompaniments defeat the plan. Option d is incorrect because dried fruit concentrates potassium as water leaves it, melon ranks high, and legumes add still more. Three high sources on one tray shows the teaching did not land.

Correct Answer: Offering toileting every two hours

Scheduled toileting is a standardized comfort and safety routine within the assistive role. It reduces episodes of incontinence and unsupervised attempts to reach the bathroom, which is where these clients fall. Option b is incorrect because restraint decisions rest on nursing judgment and a provider order, and restraints worsen delirium. Less restrictive measures such as a low bed and frequent orientation come first. Option c is incorrect because reading laboratory results requires clinical analysis that assistive staff are not licensed to perform. They may report a value that has been posted, but the meaning belongs to the nurse. Option d is incorrect because health teaching cannot be delegated, since it demands assessment of readiness and evaluation of what was learned. Assistants may reinforce a point already taught by the nurse.

Correct Answer: Check for kinks and reposition the client

Mechanical causes come first, so the nurse straightens the tubing, confirms clamps are open, lowers the bag below the abdomen and turns the client side to side. Constipation is the next thing to check. Option a is incorrect because reversible nursing measures have not been tried in a client who is stable and pain free. A call becomes appropriate once repositioning, kink checks and a bowel assessment fail to restore outflow. Option b is incorrect because forcing fluid into the catheter without an order can drive a clot deeper or injure tissue. Irrigation is a prescribed intervention, not an independent one, in peritoneal access. Option c is incorrect because adding two more liters on top of fluid already trapped raises intraabdominal pressure. The client would develop breathlessness, pain and eventually a leak, and the retained volume shows up as weight gain.

Correct Answer: Restless movement that no position relieves

Renal colic comes in waves as the ureter spasms against the stone, so the client writhes and paces searching for relief. Peritoneal inflammation does the opposite, keeping the client rigidly motionless because movement worsens pain. Option a is incorrect because rebound tenderness and involuntary guarding belong to peritoneal irritation from a ruptured or inflamed abdominal organ. That client protects the abdomen and refuses to move, which is the opposite of the picture described here. Option b is incorrect because a steady ache relieved by lying flat suggests muscular back strain rather than ureteral obstruction. A stone generates surges of pain that follow ureteral peristalsis and no posture will settle them. Option d is incorrect because slow suprapubic pressure building over hours points toward a distended bladder from retention. Stone pain arrives abruptly at full intensity and centers in the flank before it travels toward the groin.

Correct Answer: Bacterial infection limited to the lower tract

Nitrites signal gram negative organisms, and leukocyte esterase signals white cells, so bacterial infection is confirmed. Casts are made in tubules, and their absence with only local symptoms keeps the problem in the bladder. Option b is incorrect because glomerular disease shows red cell casts and protein rather than nitrites. Enzymes released by bacteria and white cells have no role in an immune complex process. Option c is incorrect because the report contains no white cell casts and the client has no fever, chills or flank tenderness. Kidney involvement would announce itself with systemic illness. Option d is incorrect because contamination is suspected when three or more organisms grow on culture, not when a dipstick turns positive. These findings match her symptoms and support treating rather than repeating.

Correct Answer: Rinse the mouth with cool water often

Frequent mouth rinsing, ice chips counted as half volume and sugar free candy relieve thirst without spending the allowance. Cutting sodium matters too, since salt is what drives the craving. Option a is incorrect because emptying the entire allowance early leaves nothing for the long afternoon and evening. Spreading small amounts across the whole day is what makes the restriction bearable. Option b is incorrect because sodium is the very thing that generates thirst and pulls water into the circulation. Salty foods would worsen the craving while adding edema and raising blood pressure. Option d is incorrect because broth counts fully toward the allowance and carries a heavy sodium load besides. Anything liquid at room temperature must be measured and recorded as intake.

Correct Answer: Rising blood urea nitrogen with red cell casts

Immune complex injury to the glomeruli drops filtration, so blood urea nitrogen and creatinine climb while red cells leak through the damaged barrier and mold into casts inside the tubules. Option b is incorrect because creatinine rises rather than falls when filtration is lost. White cell casts point to infected kidney tissue and belong to pyelonephritis, not to immune mediated glomerular inflammation. Option c is incorrect because a clean urinalysis is impossible once the filtration barrier is inflamed. Protein spills into the urine, so serum albumin drifts downward instead of rising above its usual value. Option d is incorrect because nitrogenous waste accumulates when the kidney stops clearing it, driving that value up. Sugar in the urine reflects hyperglycemia crossing the renal threshold and has no part in this diagnosis.

Correct Answer: Greater independence with gentler fluid shifts

Peritoneal dialysis is done at home on the client's own schedule, and fluid comes off continuously rather than in a rapid burst, so hypotension and cramping are far less common. Dietary limits also loosen. Option a is incorrect because the abdomen is opened to the outside several times a day, and peritonitis is the leading complication of this therapy. Infection risk shifts location rather than disappearing. Option b is incorrect because potassium and fluid allowances become more liberal, not unlimited. Protein intake actually has to rise because albumin drains away in the effluent, so the diet changes shape instead of vanishing. Option c is incorrect because a thrice weekly schedule describes in center hemodialysis. Peritoneal dialysis runs every single day, either as four manual exchanges or as a cycler working through the night.

Correct Answer: Scan the bladder to measure retained urine

Bladder scanning gives an immediate, non invasive measure of how much urine is trapped, which turns a suspicion into data and justifies catheterization. Assessment precedes intervention, and this scan takes under a minute with no infection risk. Option a is incorrect because pouring more fluid into a bladder that cannot empty raises pressure and pain, and waiting two hours risks detrusor damage. Acute retention is an emergency that needs decompression, not observation. Option c is incorrect because tamsulosin needs days to relax prostatic smooth muscle and does nothing for a bladder that is already full tonight. Drug therapy belongs to long term management of the obstruction. Option d is incorrect because warmth may relax the perineum a little and is a reasonable comfort measure once the volume is known. Used alone it leaves an overdistended bladder undrained while the client keeps suffering.

Correct Answer: Collecting a specimen from the drainage bag

Urine sitting in the bag has been colonized and no longer represents bladder urine, so the culture misleads. Samples come from the disinfected sampling port with a sterile syringe after brief clamping. Option a is incorrect because anchoring the tubing prevents traction on the urethra and the small mucosal tears that follow. Securement is part of the maintenance bundle and needs no correction. Option b is incorrect because gravity drainage below the level of the bladder stops contaminated urine from flowing backward. This positioning is exactly what the graduate should be doing, provided the bag stays off the floor. Option d is incorrect because routine daily meatal care uses plain soap and water. Antiseptic scrubs have never been shown to reduce infection and simply irritate the tissue, so this practice is correct.

Correct Answer: Between 100 and 400 milliliters

The course defines the oliguric phase by an output of 100 to 400 milliliters in a day. Filtration has collapsed, so waste and fluid accumulate while the client barely makes urine. Option b is incorrect because roughly a liter of urine daily falls within the normal adult range. A client producing that volume is not oliguric, and the kidney is still clearing an ordinary solute load. Option c is incorrect because output near two liters describes healthy kidneys working normally. Recording that amount in acute kidney injury would suggest the nonoliguric pattern or the return of function during recovery. Option d is incorrect because volumes of several liters belong to the diuretic phase, when tubules filter again yet cannot concentrate. That picture threatens dehydration and potassium loss rather than retention of fluid.

Correct Answer: Activate the rapid response sepsis protocol

Fever with hypotension, tachycardia, mottled skin and altered mentation is urosepsis progressing toward septic shock. Escalating immediately starts oxygen, fluids and rapid antibiotic delivery, because circulation is failing and time is the therapy. Option a is incorrect because oral intake cannot restore perfusion in a client whose pressure is already falling, and waiting wastes the narrow window in which shock is still reversible. Option c is incorrect because comfort measures address delirium as though the environment caused it. The cool mottled skin and low pressure point instead to failing tissue perfusion demanding an emergency response. Option d is incorrect because withholding antimicrobial coverage during evolving sepsis raises mortality with every hour lost. Cultures were already obtained at admission, so nothing is gained by delaying the scheduled dose.

Correct Answer: "Those products contain potassium and are unsafe."

Most salt substitutes are potassium chloride, and a client who cannot excrete potassium can reach a fatal level quickly. Herbs, lemon, vinegar and garlic season food without that risk. Option a is incorrect because even small amounts of potassium chloride add up in someone whose kidneys clear almost none of it. Portion control does not make the product acceptable. Option b is incorrect because blood pressure control has no bearing on whether the kidney can handle a potassium load. The hazard stays constant no matter how well hypertension is managed. Option c is incorrect because a trial period invites a rhythm disturbance that may present as sudden arrest rather than a warning symptom. Nurses do not test tolerance for a lethal electrolyte.

Correct Answer: Bladder bacteria climbed the ureters into the kidney

Most pyelonephritis is ascending. An untreated bladder infection, usually Escherichia coli, travels up the ureters into the renal pelvis and kidney tissue, which is why early treatment of cystitis matters so much. Option a is incorrect because bloodborne seeding accounts for only a minority of cases, typically with staphylococcal bacteremia or immunosuppression. This client described two weeks of untreated lower tract symptoms instead. Option c is incorrect because immune complex deposition damages the filtering tufts and produces glomerulonephritis. That process follows a strep infection after a latent period and involves no bacteria inside the kidney. Option d is incorrect because mechanical irritation of the urothelium is not how kidney infection begins. Her story of neglected dysuria points to organisms that were left to multiply and move upward.

Correct Answer: Tenderness over the costovertebral angle

Costovertebral angle tenderness on gentle percussion localizes inflammation to kidney tissue. Combined with rigors and vomiting it marks the move from bladder infection to pyelonephritis, which needs a different drug and often admission. Option a is incorrect because suprapubic tenderness reflects an inflamed bladder wall and was already present with her cystitis. It says nothing about whether organisms have climbed the ureters into kidney tissue. Option b is incorrect because cloudy foul urine appears with any bacterial infection of the tract, upper or lower. A finding shared by both diagnoses cannot separate them for this caller. Option d is incorrect because urgency and small voids are storage symptoms generated in the bladder itself. These belong to the original lower tract picture rather than to the systemic illness she now describes.