a nurse prepares a client for a percutaneous kidney biopsy which actions should the nurse take prior to this procedure select all that apply

HESI RN

RN Medical/Surgical NGN HESI 2023

1. Prior to a percutaneous kidney biopsy, which actions should a nurse take? (Select all that apply.)

A. Keep the client NPO for 4 to 6 hours.
B. Obtain coagulation study results.
C. Maintain strict bedrest in a supine position.
D. A & B

Correct answer: D

Rationale: Prior to a percutaneous kidney biopsy, the nurse should ensure that the client is kept NPO for 4 to 6 hours to prevent aspiration during the procedure. Obtaining coagulation study results is crucial to assess the risk of bleeding during and after the biopsy. Strict bedrest in a supine position is not necessary before the procedure. It is important to note that blood pressure medications should be carefully managed, but it is not a pre-procedure action. Keeping the client on bedrest or assessing for blood in the urine are interventions that are more relevant post-procedure to monitor for complications.

2. When performing a health history on a patient who is to begin receiving a thiazide diuretic to treat heart failure, the nurse will be concerned about a history of which condition?

A. Asthma
B. Glaucoma
C. Gout
D. Hypertension

Correct answer: C

Rationale: Thiazide diuretics block uric acid secretion, leading to elevated levels that can contribute to gout. Therefore, patients with a history of gout should take thiazide diuretics with caution. Asthma (Choice A), Glaucoma (Choice B), and Hypertension (Choice D) are not directly contraindicated with thiazide diuretics, making choices A, B, and D incorrect.

3. A client with diabetes mellitus is scheduled to have blood drawn for a fasting blood glucose determination in the morning. What does the nurse tell the client is acceptable to consume on the morning of the test?

A. Water
B. Tea without sugar
C. Coffee without milk
D. Clear liquids like apple juice

Correct answer: A

Rationale: The correct answer is A: Water. A client scheduled for a fasting blood glucose test should only consume water after midnight to ensure accurate test results. Choosing options B, C, or D, which include tea, coffee, or clear liquids like apple juice, is incorrect as they may contain substances that can affect the blood glucose levels, leading to inaccurate test results.

4. During an assessment on a patient brought to the emergency department for treatment for dehydration, the nurse notes a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse observes cool, clammy skin. Which diagnosis does the nurse suspect?

A. Fluid volume deficit (FVD)
B. Fluid volume excess (FVE)
C. Mild extracellular fluid (ECF) deficit
D. Renal failure

Correct answer: A

Rationale: The nurse should suspect Fluid Volume Deficit (FVD) in this patient. Signs of FVD include elevated temperature, tachycardia, tachypnea, hypotension, orthostatic hypotension, and cool, clammy skin, which align with the patient's assessment findings. Choices B, C, and D are incorrect. Fluid Volume Excess (FVE) typically presents with bounding pulses, elevated blood pressure, dyspnea, and crackles. Mild extracellular fluid (ECF) deficit usually manifests as thirst. Renal failure commonly results in Fluid Volume Excess (FVE) rather than Fluid Volume Deficit (FVD).

5. In the staging process of Hodgkin's disease, what does Stage I indicate?

A. Involvement of a single lymph node.
B. Involvement of two or more lymph nodes on the same side of the diaphragm.
C. Involvement of lymph node regions on both sides of the diaphragm.
D. Involvement of diffuse disease of one or more extralymphatic organs.

Correct answer: A

Rationale: In the staging process of Hodgkin's disease, Stage I signifies the involvement of a single lymph node. This stage indicates localized disease with the disease being limited to a single lymph node or a group of adjacent nodes. Choices B, C, and D are incorrect because they describe more extensive involvement of lymph nodes, both sides of the diaphragm, or extralymphatic organs, which would correspond to higher stages in the staging system.