52. A nurse is developing a nursing care plan for a patient in the diuresis stage of Acute renal failure. What nursing diagnosis needs to be included in the care plan? A. Excess fluid volume B. Risk for electrolyte imbalance C. Urinary retention D. Acute pain 53. A 15-year-old patient is experiencing acute glomeruloneph ritis. What signs and symptoms is rare with this condition? A. Swelling in the face B . Hyperlipidemia C. Cola colored urine D. Elevated BUN and creatinine level 54. A patient who has difficulty voiding urine , explains that he has severe colicky excruciating pain at the lower quadrant of the abdomen which radiates to the scrotum . Which area is the most probable caliculi formation? A. Ureter B. Kidney C. Urethra D. Bladder 55. A nurse is providing discharge teaching to a female patient on how to prevent urinary tract infections. Which statement by the patient needs re -education? A. "Void immediately after sexual intercourse." B. "Avoid wearing tight fitting underwear." C. "Try to void every 2-3 hours" D. "Use perfumed tampons during menstruation." 56. A client has a full loss of skin tissue that extended to the subcutaneous tissue. What is the stage of pressure ulcer? A. I B. II C. III D. IV 57. A nurse assesses the skin of a patient who has been bed-ridden for long to find a full thickness tissue loss extending to the bone at the back. What is the stage of the bedsore? A. I B. II C. III D. IV 58. The burned area of a patient who has experienced a burn on the right leg contains small blisters which are extremely pinkish red and shiny.The patient reports severe pain.What is the degree of burn? A. 1st Degree (superficial) B. 2nd Degree (partial-thickness) C. 3rd Degree (full-thickness) D. 4th Degree (deep full-thickness) 59. A 58 -year-old female patient has superficial partial-thickness ; burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines , calculate the total body surface area percentage that is burned. A. 63% B. 82% C 72% D. 54%

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52. A nurse is developing a nursing care plan for a patient in the diuresis stage of Acute renal failure. What nursing diagnosis needs to be included in the care plan? A. Excess fluid volume B. Risk for electrolyte imbalance C. Urinary retention D. Acute pain 53. A 15-year-old patient is experiencing acute glomeruloneph ritis. What signs and symptoms is rare with this condition? A. Swelling in the face B . Hyperlipidemia C. Cola colored urine D. Elevated BUN and creatinine level 54. A patient who has difficulty voiding urine , explains that he has severe colicky excruciating pain at the lower quadrant of the abdomen which radiates to the scrotum . Which area is the most probable caliculi formation? A. Ureter B. Kidney C. Urethra D. Bladder 55. A nurse is providing discharge teaching to a female patient on how to prevent urinary tract infections. Which statement by the patient needs re -education? A. "Void immediately after sexual intercourse." B. "Avoid wearing tight fitting underwear." C. "Try to void every 2-3 hours" D. "Use perfumed tampons during menstruation." 56. A client has a full loss of skin tissue that extended to the subcutaneous tissue. What is the stage of pressure ulcer? A. I B. II C. III D. IV 57. A nurse assesses the skin of a patient who has been bed-ridden for long to find a full thickness tissue loss extending to the bone at the back. What is the stage of the bedsore? A. I B. II C. III D. IV 58. The burned area of a patient who has experienced a burn on the right leg contains small blisters which are extremely pinkish red and shiny.The patient reports severe pain.What is the degree of burn? A. 1st Degree (superficial) B. 2nd Degree (partial-thickness) C. 3rd Degree (full-thickness) D. 4th Degree (deep full-thickness) 59. A 58 -year-old female patient has superficial partial-thickness ; burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines , calculate the total body surface area percentage that is burned. A. 63% B. 82% C 72% D. 54%

Answer 1

52. B. Risk for electrolyte imbalance53. B. Hyperlipidemia54. A. Ureter55. D. "Use perfumed tampons during menstruation."56. D. IV57. D. IV58. B. 2nd Degree (partial-thickness)59. C. 72%

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