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HURST REVIEW NCLEX-RN Readiness Exam 1-
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The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication?
- 1 minute
- 2 minutes
- 5 minutes
- 10 minutes - 2. Correct: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes.
- Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Giving this dose over only one minute could lead to these or other potential harmful effects.
- Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Five minutes would be longer than required to be able to safely administer the medication.
- Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Ten minutes is much longer than required to be able to safely administer the medication.
The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication?
- 1 minute
- 2 minutes
- 5 minutes
- 10 minutes - 2. Correct: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes.
HURST REVIEW NCLEX-RN Readiness Exam 1-
|3688 Questions and Answers Latest Updated
2024 Attained Grade A+. Top Rated For Definate
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- Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Giving this dose over only one minute could lead to these or other potential harmful effects.
- Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Five minutes would be longer than required to be able to safely administer the medication.
- Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Ten minutes is much longer than required to be able to safely administer the medication.
A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction?
- Relieve nausea
- Reduce pancreatic secretions
- Control fluid and electrolyte imbalance
- Remove the precipitating irritants - 2. Correct: In clients with pancreatitis, the pancreatic enzymes cannot exit the pancreas. These enzymes, when activated, begin to digest the pancreas itself. The enzymes become activated in the pancreas when fluid or food accumulates in the stomach. The goal in treating this client is to stop the activation of the pancreatic enzymes. Treatment is focused on keeping the stomach empty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion (pancreas digesting itself) is painful for the client and can lead to other problems such as bleeding.
- Incorrect: The primary purpose of the NG tube to suction is to keep the stomach empty and dry to decrease pancreatic enzyme production, not to relieve nausea.
- Incorrect: Because gastric contents are removed, the NG tube to suction may lead to fluid and electrolyte disturbances rather than helping to control them.
HURST REVIEW NCLEX-RN Readiness Exam 1-
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- Regular practice protocols. - 1., 2., 3. & 5. Correct: Everyone should be aware of safe zones within the school. Personnel should be given this information and signs posted in safe zones. There must be systems in place to accurately determine the number of people in the building at any given time. There also must be a system in place to alert personnel and students of tornado warnings. Regular practice prepares everyone for an actual event.
- Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof. Safe zones should be on interior walls, no windows, and a strong concrete floor if possible.
The nurse is working with a committee at the local school to develop an emergency preparedness plan for tornados. What should be included in the plan?
- Identification of safe zones.
- Methods for accounting for all people present in the building.
- Warning system activation.
- Identification of the gymnasium as the routine safe place.
- Regular practice protocols. - 1., 2., 3. & 5. Correct: Everyone should be aware of safe zones within the school. Personnel should be given this information and signs posted in safe zones. There must be systems in place to accurately determine the number of people in the building at any given time. There also must be a system in place to alert personnel and students of tornado warnings. Regular practice prepares everyone for an actual event.
- Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof. Safe zones should be on interior walls, no windows, and a strong concrete floor if possible.
What should a nurse teach family members prior to them entering the room of a client who has agranulocytosis?
- Meticulous hand washing is needed.
- Do not visit if you have any infection.
- The client must wear a mask.
- Children under 12 may not visit.
- Flowers are not allowed in the room. - 1., 2., 4., & 5. Correct: Protective isolation is needed for this client because of the presence of a low white blood cell count. We are protecting the client from acquiring an infection. So any visitors will need to have meticulous hand washing prior to entering. The visitor should not enter if he or she has any type of infection. To decrease the risk of infection, small children should not visit. Even the mildest symptom of infection could be detrimental to the client. Flowers have bacteria and should not be brought into the room.
HURST REVIEW NCLEX-RN Readiness Exam 1-
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- Incorrect: A mask must be worn by the visitor, not the client. The mask is worn by visitors to prevent a possible spread of an airborne infection to the immunocompromised client.
What should a nurse teach family members prior to them entering the room of a client who has agranulocytosis?
- Meticulous hand washing is needed.
- Do not visit if you have any infection.
- The client must wear a mask.
- Children under 12 may not visit.
- Flowers are not allowed in the room. - 1., 2., 4., & 5. Correct: Protective isolation is needed for this client because of the presence of a low white blood cell count. We are protecting the client from acquiring an infection. So any visitors will need to have meticulous hand washing prior to entering. The visitor should not enter if he or she has any type of infection. To decrease the risk of infection, small children should not visit. Even the mildest symptom of infection could be detrimental to the client. Flowers have bacteria and should not be brought into the room.
- Incorrect: A mask must be worn by the visitor, not the client. The mask is worn by visitors to prevent a possible spread of an airborne infection to the immunocompromised client.
A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation?
- Are you having trouble sleeping at night?
- Do you have periods of muscle jerking?
- Are you having any sexual dysfunction?
- Is your mood improving? - 2. Correct: Myoclonus, high body temperature, shaking, chills, and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal.
- Incorrect: Sleep disturbances are common with depression. Selective serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent question needed for assessment of this client. You should be concerned with the more serious or life-threatening issue.
HURST REVIEW NCLEX-RN Readiness Exam 1-
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- Decreased body temperature
- Constipation
- Increased heart rate - 1., 2. & 5. Correct: Serotonin syndrome is a group of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal.
- Incorrect: Increased body temperature is expected as is increased diaphoresis.
- Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome.
A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment?
- Fever and shivering
- Agitation
- Decreased body temperature
- Constipation
- Increased heart rate - 1., 2. & 5. Correct: Serotonin syndrome is a group of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal.
- Incorrect: Increased body temperature is expected as is increased diaphoresis.
- Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome.
The emergency department nurse is assessing a client who presents with severe epigastric pain. The client reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation?
HURST REVIEW NCLEX-RN Readiness Exam 1-
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- pH - 7.49, pCO2 - 40, HCO3 - 30
- pH - 7.32, pCO2 - 48, HCO3 - 20
- pH - 7.38, pCO2 - 52, HCO3 - 32
- pH - 7.29, pCO2 - 54, HCO3 - 26 - 1. Correct: These ABGs are indicative of metabolic alkalosis. The pH is high, the pCO2 is within normal limits and the bicarb is high (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolic alkalosis.
- Incorrect: The client is not hypoventilating and would not be in metabolic acidosis because he ate 3 rolls of Tums which is a base. These ABGs are indicative of acidosis. The pH is low (acidosis), the pCO2 is high (acidosis) and the bicarb is low (acidosis).
- Incorrect: The client is not a long-term COPD client as these ABGs might suggest. These ABGs are indicative of fully compensated respiratory acidosis. The pH is normal. The pCO2 is high (as with chronic retention) and the bicarb is high to help compensate.
- Incorrect: These ABGs are the result of an acute ventilation problem. They are indicative of respiratory acidosis. The pH is low, the pCO2 is high, and the bicarb is normal. No compensation has begun at this point.
The emergency department nurse is assessing a client who presents with severe epigastric pain. The client reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation?
- pH - 7.49, pCO2 - 40, HCO3 - 30
- pH - 7.32, pCO2 - 48, HCO3 - 20
- pH - 7.38, pCO2 - 52, HCO3 - 32
- pH - 7.29, pCO2 - 54, HCO3 - 26 - 1. Correct: These ABGs are indicative of metabolic alkalosis. The pH is high, the pCO2 is within normal limits and the bicarb is high (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolic alkalosis.
- Incorrect: The client is not hypoventilating and would not be in metabolic acidosis because he ate 3 rolls of Tums which is a base. These ABGs are indicative of acidosis. The pH is low (acidosis), the pCO2 is high (acidosis) and the bicarb is low (acidosis).
HURST REVIEW NCLEX-RN Readiness Exam 1-
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- Incorrect: A face shield is used when there is risk of splashing or spraying of blood or body fluids. This is not required for airborne precautions.
- Incorrect: Negative pressure is required in order to prevent the airborne infection from spreading outside of the room. Positive pressure is used only in protective environments such as when immunocompromised clients require protection from potential infectious agents outside of the room.
A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate?
Place in the correct priority order.
Assess newborn's airway and breathing.
Bulb suction excessive mucus.
Assess newborn's heart rate.
Place identification bands on newborn and mom.
Administer sterile ophthalmic ointment containing 0.5% erythromycin. - Remember Maslow's hierarchy of needs will guide your assessment. First, Assess newborn's airway and breathing. The most critical change that a newborn must make physiologically is the initiation of breathing. The nurse should assess the newborn's crying. If the cry is weak, it may indicate a respiratory disturbance. Other signs of respiratory compromise may include: stridor, grunting, retractions, apnea or diminished breath sounds. Normal respiration are 30 - 60 breaths a minute.
Second, Bulb suction excessive mucus. It is important to assure that the throat and nose are kept clean of secretions to prevent respiratory distress.
Third, Assess newborn's heart rate. If there is no respiratory distress, the nurse continues the assessment by checking the heart rate and other vital signs.
HURST REVIEW NCLEX-RN Readiness Exam 1-
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Fourth, Place identification bands on newborn and mom. These are critical for ensuring babies and moms will be appropriately matched at all times but does not take priority over respiration and circulation.
Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin. This is a legally required prophylactic eye treatment to prevent Neisseria gonorrhea. However, this would never be a priority over Maslow's hierarchy of needs.
A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate?
Place in the correct priority order.
Assess newborn's airway and breathing.
Bulb suction excessive mucus.
Assess newborn's heart rate.
Place identification bands on newborn and mom.
Administer sterile ophthalmic ointment containing 0.5% erythromycin. - Remember Maslow's hierarchy of needs will guide your assessment. First, Assess newborn's airway and breathing. The most critical change that a newborn must make physiologically is the initiation of breathing. The nurse should assess the newborn's crying. If the cry is weak, it may indicate a respiratory disturbance. Other signs of respiratory compromise may include: stridor, grunting, retractions, apnea or diminished breath sounds. Normal respiration are 30 - 60 breaths a minute.
Second, Bulb suction excessive mucus. It is important to assure that the throat and nose are kept clean of secretions to prevent respiratory distress.
Third, Assess newborn's heart rate. If there is no respiratory distress, the nurse continues the assessment by checking the heart rate and other vital signs.
Fourth, Place identification bands on newborn and mom. These are critical for ensuring babies and moms will be appropriately matched at all times but does not take priority over respiration and circulation.
HURST REVIEW NCLEX-RN Readiness Exam 1-
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- Incorrect: When given by the buccal route, the medication does not go through the digestive system. This means that the medication is not metabolized through the liver, and thus a lower dose can be used.
- Incorrect: Placement should be maintained until the tablet is dissolved in order to get the dosage and effects desired.
Which signs and symptoms would the nurse expect to see in a client who has taken prednisone for two months?
- Weight loss
- Decreased wound healing
- Hypertension
- Decreased facial hair
- Moon face - 2., 3. & 5. Correct: Decreased wound healing is a side effect with prolonged steroid use due to the immunosuppressive effects. All steroid medications, such as prednisone, can lead to sodium retention which then leads to dose related fluid retention. Hypertension is seen due to this fluid and sodium retention. Cushingoid appearance (moon face) is a side effect that is created from the abnormal redistribution of fat from prolonged steroid use.
- Incorrect: Within one month after corticosteroid administration, weight gain is seen rather than weight loss.
- Incorrect: Facial and body hair increase with prolonged steroid use. This excessive growth of body hair, known as hirsutism, is one of the numerous potential side effects of prednisone.
Which signs and symptoms would the nurse expect to see in a client who has taken prednisone for two months?
- Weight loss
- Decreased wound healing
- Hypertension
- Decreased facial hair
- Moon face - 2., 3. & 5. Correct: Decreased wound healing is a side effect with prolonged steroid use due to the immunosuppressive effects. All steroid medications, such as prednisone, can lead to sodium retention which then leads to dose related fluid retention. Hypertension is seen due to this fluid and sodium retention. Cushingoid appearance (moon face) is a side effect that is created from the abnormal redistribution of fat from prolonged steroid use.
HURST REVIEW NCLEX-RN Readiness Exam 1-
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- Incorrect: Within one month after corticosteroid administration, weight gain is seen rather than weight loss.
- Incorrect: Facial and body hair increase with prolonged steroid use. This excessive growth of body hair, known as hirsutism, is one of the numerous potential side effects of prednisone.
A nurse is at highest risk for blood-borne exposure during which situation?
- When removing a needle from the syringe.
- While placing a suture needle into the self-locking forceps.
- Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse.
- A clean needle sticks the nurse through blood-soiled gloves. - 4. Correct: A clean needle that moves through blood-soiled gloves to stick the nurse is considered to be potentially contaminated and results in a blood-borne exposure. All other answers are considered a clean stick.
- Incorrect: This is considered a clean stick. The needle is sterile initially and has not been contaminated prior to removal of the needle from the syringe.
- Incorrect: This is considered a clean stick since the suture needle has not been inserted into the client prior to the needle stick.
- Incorrect: This is considered a clean stick. The IV insertion device is sterile and has not been contaminated since it was not inserted into the client.
A nurse is at highest risk for blood-borne exposure during which situation?
- When removing a needle from the syringe.
- While placing a suture needle into the self-locking forceps.
- Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse.
- A clean needle sticks the nurse through blood-soiled gloves. - 4. Correct: A clean needle that moves through blood-soiled gloves to stick the nurse is considered to be potentially contaminated and results in a blood-borne exposure. All other answers are considered a clean stick.
HURST REVIEW NCLEX-RN Readiness Exam 1-
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- Suggest that the new nurse reconsider the client's developmental needs.
- Check the prescription order and the client dose.
- Observe the new nurse administer the medication. - 2. Correct: Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness.
- Incorrect: There is nothing in the stem about a problem with the medication dose or route.
- Incorrect: There is nothing in the stem about a problem with the medication dose or route.
- Incorrect: This is an appropriate action. However, it is not the priority over ensuring that the new nurse knows how to appropriately prepare the medication for this client.
An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care?
- Vital sign checks every 15 min x 4
- Supine position for 6 hours
- NPO until return of gag reflex
- Irrigate NG tube every 2 hours
- Raise four side rails - 1., & 3. Correct: Vital signs post procedure are important to monitor for any post-procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns.
- Incorrect: Supine position for 6 hours is contraindicated. The HOB should be elevated. In the event the client vomits, he/she is less likely to aspirate with the HOB elevated. Supine position for 6 hours is used after a heart catheterization.
- Incorrect: A client who is going for a gastroscopy procedure cannot have a nasal gastric tube. An NG tube would interfere with the procedure.
HURST REVIEW NCLEX-RN Readiness Exam 1-
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- Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked position. Raise three side rails, and have call light within reach.
An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care?
- Vital sign checks every 15 min x 4
- Supine position for 6 hours
- NPO until return of gag reflex
- Irrigate NG tube every 2 hours
- Raise four side rails - 1., & 3. Correct: Vital signs post procedure are important to monitor for any post-procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns.
- Incorrect: Supine position for 6 hours is contraindicated. The HOB should be elevated. In the event the client vomits, he/she is less likely to aspirate with the HOB elevated. Supine position for 6 hours is used after a heart catheterization.
- Incorrect: A client who is going for a gastroscopy procedure cannot have a nasal gastric tube. An NG tube would interfere with the procedure.
- Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked position. Raise three side rails, and have call light within reach.
The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse?
- The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used.
- Benztropine is given to treat the side effects produced by the chlorpromazine.
- Chlorpromazine is used for severe hiccups that can occur with the use of benztropine.
- Chlorpromazine is used for psychosis and benztropine is used for preventing agranulocytosis. - 2. Correct: Benztropine is used to treat parkinsonism of various causes and drug-induced extrapyramidal reactions seen with chlorpromazine, which is an antipsychotic agent. Extrapyramidal symptoms are neurologic disturbances in the area of the brain that controls motor coordination. This disruption can cause symptoms that mimic Parkinson's disease, including stiffness, rigidity, tremor, drooling
HURST REVIEW NCLEX-RN Readiness Exam 1-
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A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include?
- Do not keep secrets for the suicidal person.
- Express concern for a person expressing thoughts of suicide.
- Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well.
- Inform group of suicide intervention sources.
- Do not leave a suicidal person alone. - 1., 2., 4. & 5. Correct: If a person reveals that suicide is being considered, this should never be kept secret. Help should be sought for the person immediately. It is also important to be direct and non-secretive with suicidal clients. It is appropriate to express concern for their thoughts. The use of empathy, warmth and concern indicates to the client that their feelings are being understood and viewed as real, which helps to build trust with the client. Resources for assistance are important to include in all health teaching programs. The teens need to know what resources are readily available if someone is considering suicide. The client contemplating suicide should not be left alone. This is for the client's safety until further assistance can be obtained
- Incorrect: Most clients who commit suicide have told at least one person that they were contemplating suicide before thy actually committed the act. Therefore, suicidal comments should be considered important risk factors that require evaluation, and all comments should be taken seriously. Anyone expressing suicidal feelings needs immediate attention.
A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include?
- Do not keep secrets for the suicidal person.
- Express concern for a person expressing thoughts of suicide.
- Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well.
- Inform group of suicide intervention sources.
- Do not leave a suicidal person alone. - 1., 2., 4. & 5. Correct: If a person reveals that suicide is being considered, this should never be kept secret. Help should be sought for the person immediately. It is also important to be direct and non-secretive with suicidal clients. It is appropriate to express concern for their thoughts. The use of empathy, warmth and concern indicates to the client that their feelings are being understood and viewed as real, which helps to build trust with the client. Resources for assistance are important to include in all health teaching programs. The teens need to know what resources are readily available if someone is considering suicide. The client contemplating suicide should not be left alone. This is for the client's safety until further assistance can be obtained
HURST REVIEW NCLEX-RN Readiness Exam 1-
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- Incorrect: Most clients who commit suicide have told at least one person that they were contemplating suicide before thy actually committed the act. Therefore, suicidal comments should be considered important risk factors that require evaluation, and all comments should be taken seriously. Anyone expressing suicidal feelings needs immediate attention.
The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting?
- Creatinine 1.1 mg/dl (97.24 mmol/L)
- Urinary output of 150 mL per hour.
- Gradual increase of BUN levels.
- Calcium levels of 9.0 mg/dL (2.25 mmol/L) - 3. Correct. Gradual accumulation of nitrogenous wastes results in elevated BUN and serum creatinine. This is an indication of impaired renal function.
- Incorrect. This is a normal creatinine level. Gradual accumulation of nitrogenous wastes from impaired renal function results in elevated BUN and serum creatinine.
- Incorrect. This is a normal output level. This level alone would not necessarily be an indicator of acute renal failure and that value alone would not warrant reporting it to the primary healthcare provider.
- Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is considered normal. When observing for renal functioning you would assess the BUN and creatinine levels. In addition, the calcium level may drop (hypocalcemia) in renal failure inverse relationship change due to the rising serum phosphate levels. However, the calcium level presented is within normal limits (WNL).
The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting?
- Creatinine 1.1 mg/dl (97.24 mmol/L)
- Urinary output of 150 mL per hour.
- Gradual increase of BUN levels.
- Calcium levels of 9.0 mg/dL (2.25 mmol/L) - 3. Correct. Gradual accumulation of nitrogenous wastes results in elevated BUN and serum creatinine. This is an indication of impaired renal function.
