the nurse is assessing a client with chronic kidney disease ckd which finding is most important for the nurse to respond to first
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HESI Medical Surgical Practice Exam Quizlet

1. The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first?

Correct answer: A

Rationale: The correct answer is A. Potassium level of 6.0 mEq/L indicates hyperkalemia, which is a critical electrolyte imbalance in clients with chronic kidney disease. Hyperkalemia can lead to life-threatening arrhythmias, making it the priority finding to address. Choice B, a daily urine output of 400 ml, may indicate decreased kidney function but does not pose an immediate life-threatening risk compared to hyperkalemia. Peripheral neuropathy (Choice C) and uremic fetor (Choice D) are common manifestations of CKD but are not as urgent as addressing a potentially fatal electrolyte imbalance like hyperkalemia.

2. What is an ideal goal of treatment set by the nurse in the care plan for a client diagnosed with chronic kidney disease (CKD) to reduce the risk of pulmonary edema?

Correct answer: C

Rationale: The ideal goal of treatment for a client with chronic kidney disease (CKD) to reduce the risk of pulmonary edema is to maintain a balanced intake and output. This helps in achieving optimal fluid balance, enabling the heart to eject blood effectively without increasing pressure in the left ventricle and pulmonary vessels. While maintaining oxygen saturation above 92% is important for adequate tissue oxygenation, the primary focus in this scenario is fluid balance. Absence of crackles and wheezes in lung sounds is important to assess for pulmonary status, but it is not the primary goal to prevent pulmonary edema specifically. Similarly, absence of shortness of breath at rest is a relevant goal, but the emphasis in CKD management is on fluid balance to prevent pulmonary complications.

3. Which of these methods can be used for the transfer of zygote or early embryo into the fallopian tube?

Correct answer: C

Rationale: The correct answer is C, ZIFT (Zygote Intrafallopian Transfer). ZIFT involves transferring a zygote or early embryo into the fallopian tube. GIFT (Gamete Intrafallopian Transfer - A) involves transferring unfertilized eggs and sperm into the fallopian tube for fertilization to occur inside the woman's body, not a zygote or early embryo. IUT (Intrauterine Transfer - B) is not specifically for transferring the zygote or early embryo into the fallopian tube, but rather into the uterus. ICSI (Intracytoplasmic Sperm Injection - D) is a technique where a single sperm is injected directly into an egg, not related to transferring embryos into the fallopian tube.

4. The nurse is caring for a client with DM who is experiencing ketoacidosis. The nurse should prioritize which action?

Correct answer: A

Rationale: Administering insulin intravenously is the priority action for managing diabetic ketoacidosis. Insulin helps lower blood glucose levels and halts the production of ketones, addressing the underlying cause of ketoacidosis. Giving sips of water (Choice B) may be necessary for hydration, but it does not address the immediate life-threatening issue of ketoacidosis. Monitoring urine output (Choice C) is important for assessing renal function but is not the priority over administering insulin. Applying a heating pad (Choice D) is not indicated and can potentially worsen the condition in ketoacidosis.

5. An elderly patient has been living in a nursing home for several years. The nursing staff has begun to notice a change in her behavior. All of the following are symptoms of depression except:

Correct answer: D

Rationale: Hyperorality is not typically a symptom of depression. Symptoms of depression often include changes in sleep patterns, eating patterns with weight loss, and excessive fatigue. Hyperorality, which refers to the tendency to examine, chew, or ingest non-nutritive substances, is not a common symptom associated with depression.

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