What nursing assessment finding would suggest inadequate renal perfusion in a patient being stabilized after an acute coronary syndrome (myocardial infarction)?

Low urine osmolarity and creatinine clearance.

Decreasing serum blood urea nitrogen (BUN) level.

Urine output of less than 30 mL/hr.

Urine specific gravity of less than 1.010.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Low urine osmolarity and creatinine clearance are not the primary indicators of inadequate renal perfusion in a patient being stabilized after an acute coronary syndrome. These measures reflect the concentration of the urine and the kidney’s ability to filter waste from the blood, respectively. While they can be affected by renal perfusion, they are not the most direct or reliable indicators.
Choice B rationale
A decreasing serum blood urea nitrogen (BUN) level is not typically associated with inadequate renal perfusion. In fact, a high BUN level may indicate that the kidneys aren’t working properly. However, BUN levels can be influenced by many factors, including protein intake and liver function, so they are not the most reliable indicator of renal perfusion.
Choice C rationale
A urine output of less than 30 mL/hr is a common sign of inadequate renal perfusion. The kidneys need adequate blood flow to filter waste products from the blood and produce urine. If renal perfusion is inadequate, urine output can decrease.
Choice D rationale
A urine-specific gravity of less than 1.010 is not typically associated with inadequate renal perfusion. Specific gravity is a measure of the concentration of solutes in the urine. It can be influenced by hydration status and certain kidney disorders, but it is not a direct measure of renal perfusion.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale
A 65-year-old male recovering from right lobectomy for treatment of lung cancer is at risk for developing sepsis. Post-surgical patients, especially those with cancer, are at increased risk due to potential infection at the surgical site and a weakened immune system from the cancer and/or its treatment.
Choice B rationale
A 78-year-old female with diabetes mellitus who is recovering from colon surgery is at risk for developing sepsis. Diabetes can impair the immune system, making it harder for the body to fight off infections. Additionally, any surgical procedure carries a risk of infection.
Choice C rationale
A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place is at risk for developing sepsis. Hospitalized patients, particularly those with invasive devices like catheters and central lines, are at increased risk due to potential introduction of bacteria into the body.
Choice D rationale
A 55-year-old male who is a recent kidney transplant recipient is at risk for developing sepsis. Transplant recipients are often on immunosuppressive therapy to prevent organ rejection, which can leave them more susceptible to infections.

A. Pulsus paradoxus. B. Exudate. C. Aneurysm. D. Tamponade.

Correct Answer is D

Explanation

Choice A rationale
Pulsus paradoxus, an exaggerated decrease in systolic blood pressure during inspiration, can be a sign of several conditions, including pericardial tamponade, constrictive pericarditis, and restrictive cardiomyopathy.
Choice B rationale
Exudate, a fluid with a high protein content that leaks out of blood vessels due to inflammation, is not typically associated with the symptoms described.
Choice C rationale
An aneurysm, a bulge or ballooning in a blood vessel, could potentially cause the symptoms described, but it is not the most concerning finding given the symptoms of edema, hepatomegaly, and muffled heart sounds.
Choice D rationale
Tamponade, a serious condition in which fluid or blood fills the pericardial sac, compressing the heart and preventing it from pumping effectively, could cause the symptoms described and would be the most concerning finding.

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What nursing assessment finding would suggest inadequate renal perfusion in a patient being stabilized after an acute coronary syndrome (myocardial infarction)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You’re providing care to four patients. Select all the patients who are at risk for developing sepsis:

Correct Answer is ["A","B","C","D"]

Explanation

A 56-year-old individual visits his primary care provider for a routine checkup.The physical examination reveals edema, an enlarged liver (hepatomegaly), and muffled heart sounds. Which of the following findings should the nurse be most concerned about?

Correct Answer is D

Explanation

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