NR-325 Adult Health II - Set 2 - Part 3

Correct Answer: Recording the daily weight each morning

Obtaining and recording weights is a routine measurement within the scope of assistive personnel. The nurse still interprets the number, compares it with yesterday, and acts on the trend. Option a is incorrect because client education requires judgment about what the person already knows and how to adapt the message. Teaching sits with the licensed nurse and cannot be handed off. Option b is incorrect because auscultating for crackles is an assessment skill that detects pulmonary edema early. Data collection of that kind stays with the nurse who can act on it. Option d is incorrect because reading a fluid balance and deciding what it means is analysis, not measurement. Assistive personnel may total the columns, yet the conclusion belongs to the nurse.

Correct Answer: Continuous renal replacement therapy in the unit

Fluid and solute come off slowly across a full day, which an unstable client on vasopressors can tolerate. Persistent low blood pressure is the defining reason this therapy is chosen over an intermittent treatment. Option a is incorrect because pulling several liters within four hours overwhelms a client whose pressure is already supported by drugs. Rapid removal in this setting deepens shock and can arrest a fragile circulation. Option b is incorrect because manual exchanges require a stable client who can manage the therapy at home. Sepsis with an intraabdominal focus and a catheter placed during shock make this option unsafe right now. Option c is incorrect because one treatment does not address ongoing acidosis, rising potassium and a mounting fluid load in a client who cannot be moved. Intermittent bursts also carry the same hemodynamic problem.

Correct Answer: Measure vital signs and oxygen saturation

Delirium of sudden onset signals a physiologic problem until proven otherwise. Vital signs and oxygen saturation screen for sepsis and hypoxia, satisfying the airway, breathing and circulation rule before any other step. Option a is incorrect because reorientation is a supportive measure that belongs later in the plan of care. It gathers no data about perfusion or oxygenation and would delay recognition of an infection. Option c is incorrect because sedating a delirious older adult deepens the confusion, raises fall risk and buries the very symptom that is signaling illness. Chemical restraint treats staff distress, not the resident. Option d is incorrect because charting records the change without acting on it. An acute mental status shift in an older adult needs assessment within minutes, and paperwork can follow once stability is established.

Correct Answer: Slow the irrigation rate while watching the color

The rate is matched to the color of the return, so clearing drainage means the nurse eases the flow back while continuing to watch. The target is a light pink outflow that stays free of clots. Option a is incorrect because clamping stops the flushing action and lets blood pool where clots form fastest. Bladder spasms are treated with an antispasmodic and reassurance, never by closing off a system designed to keep running. Option b is incorrect because stripping the tubing drives sharp pressure changes into a raw prostatic bed and can restart bleeding that had already settled. Obstruction is managed by ordered hand irrigation or by calling the surgeon. Option c is incorrect because the catheter also applies traction to the prostatic fossa and drains the bladder while healing continues. Removing it belongs to the surgeon's decision, usually once the urine has stayed clear for a day.

Correct Answer: The pattern is overflow, so this drug is contraindicated

Constant dribbling from an overdistended bladder with a large residual is overflow incontinence caused by outlet obstruction. An anticholinergic weakens detrusor contraction further and can tip this client straight into complete retention, so the nurse questions the order. Option a is incorrect because urgency incontinence features a compelling warning followed by a large loss, with an empty bladder afterward. Here the leaking never stops and the bladder stays full, which points the other direction entirely. Option b is incorrect because antimuscarinic drugs block the receptors that make the detrusor squeeze. They quiet an overactive bladder rather than energizing a tired one, so contraction becomes weaker and emptying gets worse. Option d is incorrect because cutting fluid does nothing to open an obstructed outlet and leaves urine concentrated and irritating. Relief comes from treating the prostate and draining the bladder, usually with intermittent catheterization.

Correct Answer: The potassium will rise again

Insulin only pushes potassium inside cells, and none of it left the body. As the effect wears off the potassium drifts back up, so removal and a repeat level are still needed. Option b is incorrect because the shift lasts only a few hours and reverses once insulin action fades. Continued decline would require a binder or another route of true elimination. Option c is incorrect because sodium tends to fall in oliguric kidney injury, diluted by retained water. Nothing in this regimen loads the client with enough sodium to raise the serum value. Option d is incorrect because injured tubules do not regain excretory capacity from a drug given for an electrolyte emergency. Recovery of filtration follows its own timeline over days to weeks.

Correct Answer: Metabolic acidosis with respiratory compensation

Failing kidneys cannot excrete hydrogen ion or rebuild bicarbonate, so acid accumulates. The lungs answer with deep rapid Kussmaul breathing to blow off carbon dioxide, which is respiratory compensation. Option a is incorrect because carbon dioxide retention from poor ventilation causes that disorder, and the breathing would be shallow or slow. This client is hyperventilating, not underventilating. Option c is incorrect because blowing off too much carbon dioxide from anxiety or pain raises pH. A low bicarbonate together with kidney failure points the other direction entirely. Option d is incorrect because loss of acid through vomiting or suction produces that imbalance, and bicarbonate climbs rather than falls. Compensation would be slow shallow breathing instead.

Correct Answer: A portable handheld bladder ultrasound scanner

The bladder scanner is a portable ultrasound that reads retained volume through the abdominal wall. It is painless, needs no sterile technique, carries no infection risk and can be repeated as often as the situation demands. Option b is incorrect because in and out catheterization does measure residual urine and was once the reference standard. Passing a catheter now introduces organisms, so the scanner is used first and the catheter only if the volume demands. Option c is incorrect because a collection hat captures what the client actually passes into the toilet. Voided volume says nothing about the urine still sitting in the bladder afterward, which is the number being sought. Option d is incorrect because a voiding diary tracks patterns over days, including timing, leakage and fluid intake. It is a useful record for incontinence assessment yet it cannot quantify a single residual volume at the bedside.

Correct Answer: Sodium, potassium, phosphorus, and often protein

The failing kidney cannot clear sodium, potassium or phosphorus, so all three are limited, and protein is often restricted because its breakdown generates urea and acid the kidney cannot excrete. Option a is incorrect because iron and calcium are frequently supplemented rather than limited in kidney disease. Fiber is encouraged to counter the constipation caused by binders, restricted fluid and iron. Option b is incorrect because carbohydrate and fat supply the calories that keep a client from breaking down muscle. Active vitamin D is actually prescribed, since damaged kidneys can no longer produce it. Option c is incorrect because water soluble B vitamins and folate are supplemented in a renal formula. Magnesium does need caution, yet the other three items in this list belong nowhere near the answer.

Correct Answer: Disequilibrium syndrome from rapid urea clearance

Urea leaves the blood far faster than it leaves brain tissue, so water shifts into a relatively hyperosmolar brain and causes cerebral edema. First treatments with a very high level carry the highest risk. Option a is incorrect because air entering the circuit produces sudden dyspnea, chest pain, cyanosis and a churning murmur within seconds. This client has a gradual neurologic picture rather than an abrupt cardiopulmonary collapse. Option b is incorrect because a falling pressure brings dizziness, sweating and cramps, and the blood pressure in disequilibrium typically rises instead. Confusion arising with a headache after urea drops points to the brain, not the circulation. Option d is incorrect because inflammation of the pericardium announces itself with pleuritic chest pain and a friction rub heard at the sternal border. It builds over days in undertreated clients and is an indication for dialysis.