NUR 213 Test 3 Ch.1 - disease (CKD), who is on peritoneal dialysis is...

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NUR 213 Test 3 Ch.1

• The client diagnosed with end-stage renal disease (ESRD), also known as chronic kidney

disease (CKD), who is on peritoneal dialysis is admitted to the critical care unit. Which assessment data warrants immediate intervention by the nurse?

• The client's serum creatinine level is 2.4 mg/dL.
• The client's abdomen is soft to touch and nontender.
• The dialysate being removed from the abdomen is cloudy.
• The dialysate instilled was 1500 mL and removed was 2100 mL.

Answer 3 The dialysate return should be colorless or straw colored but should never be cloudy, which indicates an infection; therefore, this data warrants immediate intervention.

• The charge nurse, along with the registered nurse (RN) staff, in the critical care unit is

caring for clients with a spinal cord injury (SCI). Which client should the charge nurse assess first after receiving the change-of-shift re- port?

• The client with a C-6 SCI who is complaining of dyspnea and has a respira- tory rate

of 12 breaths/minute.

• The client with an L-4 SCI who is frightened about being transferred to the rehabilitation

unit.

• The client with an L-2 SCI who is complaining of a headache and feeling very hot

all of a sudden.

• The client with a C-4 SCI who is on a ventilator and has a pulse oximeter reading

of 98%.

Answer 1 This client with dyspnea and a respiration rate of 12 has signs/symptoms of a respiratory complication and should be assessed first because ascending paralysis at the C-6 level could cause the client to stop breathing.

• The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is

most important for the nurse to ask during the admission interview?

• "Have you recently traveled outside the United States?"
• "Did you recently begin a vigorous exercise program?"
• "Is there a chance you have been exposed to a virus?"
• "What over-the-counter medications do you take regularly?"

Answer

• Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and some

herbal remedies are nephrotoxic; therefore, asking about medications is appropriate.

• The nurse is caring for a client diagnosed with ARF. Which laboratory values are most 1 / 4

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significant for diagnosing ARF?

• BUN and creatinine.
• WBC and hemoglobin.
• Potassium and sodium.
• Bilirubin and ammonia level.

Answer 1 Blood urea nitrogen (BUN) levels reflect the balance between the production and excretion of urea from the kidneys. Creatinine is a by-product of the metabolism of the muscles and is excreted by the kidneys. Creatinine is the ideal substance for determining renal clearance because it is relatively constant in the body and is the laboratory value most significant in diagnosing renal failure.

• The nurse is caring for a client diagnosed with rule-out ARF. Which condition predisposes the

client to developing prerenal failure?

• Diabetes mellitus.
• Hypotension.
• Aminoglycosides.
• Benign prostatic hypertrophy.

Answer 2 Hypotension, which causes a decreased blood supply to the kidney, is one of the most common causes of prerenal failure (before the kidney).

• The client is diagnosed with ARF. Which signs/symptoms indicate to the nurse the client is

in the recovery period? Select all that apply.

• Increased alertness and no seizure activity.
• Increase in hemoglobin and hematocrit.
• Denial of nausea and vomiting.
• Decreased urine-specific gravity.
• Increased serum creatinine level.

Answer

1, 2, 3

Renal failure affects almost every system in the body. Neurologically, the client may have drowsiness, headache, muscle twitching, and seizures. In the recovery period, the client is alert and has no seizure activity. In renal failure, levels of erythropoietin are decreased, leading to anemia. An increase in hemoglobin and hematocrit indicates the client is in the recovery period.Nausea, vomiting, and diarrhea are common in the client with ARF; therefore, an absence of these indicates the client is in the recovery period.

• The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which

collaborative treatment should the nurse anticipate for the client? 2 / 4

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• Administer a phosphate binder.
• Type and crossmatch for whole blood.
• Assess the client for leg cramps.
• Prepare the client for dialysis.

Answer 4 Normal potassium level is 3.5 to5.5 mEq/L. A level of 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to

decrease the potassium level quickly. This requires a health-care provider order, so it is a collaborative intervention.

• The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is an

appropriate outcome for the client?

• Monitor intake and output every shift.
• Decrease of pain by 3 levels on a 1-10 scale.
• Electrolytes are within normal limits.
• Administer enemas to decrease hyperkalemia.

Answer 3 Renal failure causes an imbalance of electrolytes (potassium, sodium, calcium, phosphorus).Therefore, the desired client outcome is electrolytes within normal limits.

• The client diagnosed with ARF is admitted to the intensive care unit and placed on a

therapeutic diet. Which diet is most appropriate for the client?

• A high-potassium and low-calcium diet.
• A low-fat and low-cholesterol diet.
• A high-carbohydrate and restricted-protein diet.
• A regular diet with six (6) small feedings a day.

Answer 3 Carbohydrates are increased to provide for the client's caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste products.

• The client diagnosed with ARF is placed on bedrest. The client asks the nurse, "Why do I

have to stay in bed? I don't feel bad." Which scientific rationale supports the nurse's response?

• Bedrest helps increase the blood return to the renal circulation.
• Bedrest reduces the metabolic rate during the acute stage.
• Bedrest decreases the workload of the left side of the heart.
• Bedrest aids in reduction of peripheral and sacral edema.

Answer 3 / 4

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2 Bedrest reduces exertion and the metabolic rate, thereby reducing catabolism and subsequent release of potassium and accumulation of endogenous waste products (urea and creatinine).

• The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical

floor. Which nursing task is most appropriate for the nurse to delegate?

• Collect a clean voided midstream urine specimen.
• Evaluate the client's 8-hour intake and output.
• Assist in checking a unit of blood prior to hanging. 4. Administer a cation-ex- change resin

enema.

Answer 1 The UAP can collect specimens. Collecting a midstream urine specimen requires

the client to clean the perineal area, to urinate a little, and then collect the rest of the urine output in a sterile container.

• The client is admitted to the emergency department after a gunshot wound to the abdomen.

Which nursing intervention should the nurse implement first to prevent ARF?

• Administer normal saline IV.
• Take vital signs.
• Place client on telemetry. 4. Assess abdominal dressing.

Answer 1 Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys. Significant blood loss is expected in the client with a gunshot wound.

• The UAP tells the nurse the client with ARF has a white crystal-like layer on top of the

skin. Which intervention should the nurse implement?

• Have the assistant apply a moisture barrier cream to the skin.
• Instruct the UAP to bathe the client in cool water.
• Tell the UAP not to turn the client in this condition.
• Explain this is normal and do not do anything for the client.

Answer 2 These crystals are uremic frost resulting from irritating toxins deposited in the client's tissues.Bathing in cool water will remove the crystals, promote client comfort, and decrease the itching resulting from uremic frost.

• The client diagnosed with ARF is experiencing hyperkalemia. Which med- ication should

the nurse prepare to administer to help decrease the potassium level?

• Erythropoietin.
• Calcium gluconate.
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