The nurse is caring for an assigned client. Which prescription requires clarification based on the laboratory data? See the exhibit. Select all that apply. Prescribed Medications: vancomycin 1-gram IVPB daily, furosemide 40 mg PO daily, 500 mL of 0.9% sodium chloride bolus x 1 dose, diltiazem XR 120 mg PO daily, Ketorolac 15 mg IV push every eight hours PRN pain. Laboratory Results: Sodium 145 mEq/L (145 mmol/L), Potassium 3.7 mEq/L (3.7 mmol/L), Calcium 9.3 mg/dL (2.32 mmol/L), BUN 25 mg/dL (8.93 mmol/L), Creatinine 2.1 mg/dL (185.64 umol/L)
Rationale:
Vancomycin 1-gram IVPB daily and ketorolac 15 mg IV push every eight hours PRN pain require clarification. The client's elevated creatinine level suggests impaired renal function, necessitating caution with these medications due to potential nephrotoxicity and adverse effects.
B: furosemide 40 mg PO daily can be safely prescribed since the potassium level is within normal limits, and it may help manage fluid overload without immediate renal concerns.
C: 500 mL of 0.9% sodium chloride bolus x 1 dose is appropriate as normal saline is safe for hydration, particularly with the current lab values indicating no electrolyte imbalances that would contraindicate its use.
D: diltiazem XR 120 mg PO daily does not require clarification, as it is not contraindicated by the client's lab results and can be safely administered for blood pressure management.
The nurse performs a physical assessment on a client and observes the client demonstrate palmar flexion while obtaining the blood pressure. The nurse should take which action?
Rationale:
Request an order for a magnesium level. Palmar flexion during blood pressure measurement may indicate neurological or electrolyte imbalances, particularly low magnesium, necessitating further investigation to ensure appropriate management and care.
A: Obtain the blood pressure on the client's calf. Measuring blood pressure in the calf does not address the underlying potential electrolyte issue indicated by the observed palmar flexion.
C: Assess the client's orthostatic blood pressure. While assessing orthostatic blood pressure is important, it does not directly relate to the concerning symptom of palmar flexion, which suggests a different underlying issue.
D: Obtain capillary blood glucose (CBG). Although blood glucose levels are crucial, palmar flexion is more indicative of possible magnesium deficiency rather than glucose abnormalities, making this option less relevant.
The nurse is assessing a client with suspected renal calculi. Which of the following findings would support a diagnosis of renal calculi? Select all that apply.
Rationale:
Hematuria, nausea and vomiting, dysuria, and increased urinary frequency support a diagnosis of renal calculi as they indicate irritation and obstruction in the urinary tract commonly associated with kidney stones.
C: hypotension does not indicate renal calculi, as this condition primarily reflects blood pressure changes rather than urinary symptoms linked to kidney stones. It lacks direct relevance to renal obstruction.
The nurse has obtained a physician's order to obtain a clean catch urine specimen from a client. The nurse should instruct the client to obtain the urine sample
Rationale:
Midstream from the bladder. This technique minimizes contamination from the urethra and surrounding skin, providing a more accurate urine sample for analysis, which is essential for proper diagnosis and treatment.
A: from the first stream of urine from the bladder. Collecting the first stream introduces contaminants that may skew test results, compromising the specimen's reliability for accurate assessment.
C: from the final stream of urine from the bladder. The final stream may contain sediment and bacteria that could distort the results, leading to misleading interpretations of the urinary analysis.
D: by emptying the entire volume of urine in the specimen cup. This method does not focus on a specific portion, increasing the risk of contamination, thus undermining the integrity of the sample collected.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 5 of 6
History and Physical
A 57-year-old male client with stage three small cell lung cancer. The client had suddenly become disoriented and did not recognize his family members and relatives. He reports severe lower extremity weakness and has had three episodes of diarrhea in the past four hours. The client is undergoing 6 cycles of chemotherapy with cisplatin and etoposide. He is currently taking a 14-day course of 15 mg of prednisone. He is on his third day of steroid treatment. He has a medical history of dyslipidemia and advanced chronic obstructive pulmonary disease.
Laboratory Results
• Hemoglobin 14 g/dL [14-18 g/dL (140–180 g/L)]
• Hematocrit 42% (0.42) [42-52% (0.42-0.52)]
• White Blood Cell 11,000 mm3 [5-10 mm3]
• Platelet Count 140,000 mm3 [150-400 mm3 (150–400 × 109/L)]
• Glucose 139 mg/dL (7.72 mmol/L) [70–110 mg/dL (4-6 mmol/L)]
• Sodium 116 mEq/L [136–145 mEq/L (mmol/L)]
• Potassium 3.3 mEq/L [3.5–5.0 mEq/L (mmol/L)]
• Creatinine 0.7 mg/dL (61.88 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Blood Urea Nitrogen 8 mg/dL (2.86 mmol/L) [10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum Osmolality 277 mOsm/kg [285-295 mOsm/kg (285–295 mmol/kg)]
Nurses' Notes
0759: Client is completely disoriented and required maximum assistance to the stretcher because of unsteady gait. Lung sounds clear bilaterally. Alopecia noted. Skin is warm and dry and normal for ethnicity. Peripheral pulses 2+. No skin tenting. Hyperactive bowel sounds in all quadrants. 20-gauge peripheral vascular access device placed in the left antecubital space. T 97.8° F (36.6° C) P 88 RR 21 BP 123/68 Pulse oximetry reading 91% on room air.
0850: Verbal order was received from physician to insert indwelling urethral catheter.
0910: Urinary catheter inserted with sterile technique. 40 mL of dark yellow urine returned.
Orders
• admit to intensive care unit
• nephrology consultation
• oncology consultation
• fluid restriction - 1 liter daily
• daily weight
• strict intake and output
• 250 mL of 3% saline at 75 mL/hr
• tolvaptan 15 mg PO daily - first dose now
• neurological assessments every two hours
The nurse reviews the orders and prepares to administer the first dose of prescribed tolvaptan. Complete the following sentences by choosing from the lists of options. Prior to administering the first dose of this medication, the nurse should obtain an order to review the client's baseline.............. as.......................... is a serious adverse effect of this medication? Osmotic demyelination syndrome is another serious adverse reaction to this medication and requires monitoring of the client's.................
Rationale:
Baseline liver enzymes should be reviewed as hepatotoxicity is a serious adverse effect of tolvaptan. Monitoring the Glasgow coma scale is critical due to the risk of osmotic demyelination syndrome, which affects neurological function.
B: thyroid toxicity Monitoring thyroid function is not directly relevant to tolvaptan administration and its main adverse effects, making this option irrelevant in this context.
C: liver injury While liver injury is a concern, the specific monitoring required is for liver enzymes to assess any potential damage effectively.
D: myocardial infarction Myocardial infarction is unrelated to tolvaptan's primary side effect profile, and thus monitoring for this condition is not warranted.
E: urinary output Although tolvaptan affects fluid balance, urinary output is not the primary concern compared to the critical need for liver enzyme monitoring.
G: blood pressure Monitoring blood pressure is not indicated as a direct concern with tolvaptan; it primarily requires attention to liver enzymes and neurological status.
The nurse is providing education to a group of nursing students regarding the causes of hypercalcemia. Which of the following information should be included? Select all that apply.
Rationale:
Thiazide diuretics, malignancy, and end-stage kidney disease are all associated with hypercalcemia. These conditions can increase calcium levels in the blood through various mechanisms, such as increased absorption or reduced excretion, which is critical knowledge for understanding patient care in nursing.
A: hypoparathyroidism. This condition typically results in hypocalcemia due to low parathyroid hormone levels, which decreases calcium mobilization from bones and absorption from the intestines.
E: Crohn's disease. While it affects nutrient absorption, it does not inherently cause hypercalcemia; instead, it often leads to deficiencies, including calcium, due to malabsorption and related complications.
The nurse is planning care for a client with a low serum albumin level. Which of the following interventions should the nurse include in the client's plan of care?
Rationale:
D: Collaborate with a registered dietician. This intervention is essential as low serum albumin levels often indicate malnutrition or inadequate protein intake. A dietician can develop a tailored nutrition plan to address these deficiencies and promote recovery.
A: Obtain a capillary blood glucose. Monitoring blood glucose levels does not directly address the underlying issues related to low serum albumin, which is primarily concerned with nutritional status.
B: Implement seizure precautions. Seizure precautions are unrelated to serum albumin levels and focus instead on preventing injury in clients with seizure disorders, not addressing nutritional deficiencies.
C: Implement strict bed rest. Strict bed rest does not improve serum albumin levels, which require dietary interventions and increased protein intake for effective management and recovery from malnutrition-related issues.
The nurse is assessing a client who was just diagnosed with acute pyelonephritis. Which of the following findings should the nurse expect to observe? Select all that apply.
Rationale:
Costovertebral angle tenderness, fever and chills, and dysuria are expected findings in a client with acute pyelonephritis. These symptoms indicate kidney inflammation and associated systemic responses, which are characteristic of this condition.
B: Jugular venous distention suggests heart failure or fluid overload, not typically associated with kidney infections like acute pyelonephritis.
D: Urinary retention is more indicative of obstructive uropathy or other urinary tract issues, rather than an infection of the kidneys.
The nurse is caring for a client with peritoneal dialysis. The client reports an outflow of only one-half of the dialysate solution that was dwelled. The nurse should instruct the client to do which of the following?
Rationale:
Encourage the client to have a bowel movement. Promoting bowel movement can alleviate any potential obstruction or constipation that may be preventing the complete outflow of the dialysate solution during peritoneal dialysis.
A: Apply heat to the abdomen. While heat may provide comfort, it does not address the underlying issue of incomplete outflow and could potentially mask symptoms requiring further assessment.
C: Strip the dialysis catheter. Stripping the catheter can risk damage or infection, and it does not specifically resolve the issue of reduced outflow, which may be related to bowel function.
D: Instill more dialysate solution. Adding more solution would not resolve the issue of inadequate outflow and could lead to overdistension or discomfort for the client, worsening the situation.
The nurse is preparing to admit a client with chronic kidney disease and congestive heart failure. Which assessment would most effectively determine the client's fluid balance?
Rationale:
Daily weight provides the most reliable assessment of a client's fluid balance, particularly for individuals with chronic kidney disease and congestive heart failure, as it reflects changes in body fluid volume efficiently.
B: Intake and output measurement offers a snapshot of fluid intake versus loss but may not accurately reflect acute changes in fluid balance like daily weight does.
C: Urine specific gravity indicates kidney function and hydration status but does not directly measure overall fluid balance, limiting its effectiveness in this context.
D: Serum sodium level can be affected by fluid status but does not provide a direct measurement of fluid balance, making it less effective for this specific assessment.
The nurse is caring for a client who has just returned from an intravenous urography procedure. Which intervention should the nurse take to prevent post-procedure acute kidney injury?
Rationale:
Encouraging the client to increase their fluid intake helps dilute the contrast dye used during the intravenous urography, promoting renal clearance and reducing the risk of acute kidney injury post-procedure.
A: Assess the venipuncture site for redness. While important for monitoring complications, it does not directly address the prevention of kidney injury following the contrast procedure.
B: Have the client obtain their daily weight for three days after the procedure. Monitoring weight does not specifically prevent acute kidney injury and is more focused on fluid status rather than contrast effects.
C: Instruct the client to remain motionless. Limiting movement does not correlate with preventing kidney injury; this approach is unrelated to the effects of contrast material on renal function.
The nurse cares for a client with a potassium of 3.2 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. Which of the following medications may cause this abnormality?
Rationale:
B: Triamterene can lead to hyperkalemia, which is a significant factor in lowering potassium levels in patients. Its potassium-sparing properties can disrupt the body's equilibrium, contributing to the client's abnormal potassium measurement.
A: Spironolactone typically causes potassium retention, increasing levels rather than decreasing them, making it unlikely to contribute to hypokalemia in this scenario.
C: Prednisone is a corticosteroid that generally does not affect potassium levels directly and is more associated with causing various electrolyte imbalances unrelated to potassium specifically.
D: Lisinopril, an ACE inhibitor, usually preserves potassium rather than depleting it, which makes it an unlikely cause of reduced potassium levels in patients.
The nurse is teaching a client who is scheduled for a 24-hour urine collection. The nurse should plan to
Rationale:
Collect and retain all urinary specimens. The initial urine specimen must be discarded to ensure accurate measurement of substances over the entire collection period, reflecting true renal function and metabolic status.
A: Discard the second urine specimen and then start the collection. This option misunderstands the protocol, as it is the first specimen that should be discarded, not the second.
B: Discard the first and last urinary specimens. Discarding both the first and last specimens would compromise the accuracy of the collection, failing to represent the full 24-hour urine output.
D: Collect and retain all urinary specimens. While retaining all specimens is essential, discarding the first specimen is necessary to avoid inaccuracies from residual urine that may not reflect true collection conditions.
The nurse is reviewing the assessment data for a client with acute glomerulonephritis (AGN). Which of the following would be an expected finding?
Rationale:
Hematuria. This condition often presents with blood in the urine, a hallmark sign of acute glomerulonephritis due to inflammation and damage to the glomeruli, impacting kidney function and urine composition.
A: Ketonuria. This finding indicates the presence of ketones in urine, typically associated with uncontrolled diabetes or starvation, not a primary feature of acute glomerulonephritis.
C: Polyuria. Increased urine output is generally linked to conditions like diabetes insipidus or uncontrolled diabetes mellitus, rather than the fluid retention and decreased output seen in acute glomerulonephritis.
D: Glycosuria. The presence of glucose in urine suggests hyperglycemia, commonly found in diabetes mellitus, which is not characteristic of acute glomerulonephritis where renal function is typically compromised.
The nurse is educating a client about a transurethral resection of the prostate (TURP). Which of the following statements should the nurse make to the client regarding this surgery?
Rationale:
A urinary catheter will remain in place following this procedure. This statement accurately reflects the postoperative care for a transurethral resection of the prostate, as the catheter facilitates urine drainage during recovery and helps monitor urinary output.
A: This surgery will remove your entire prostate. TURP only removes part of the prostate tissue to relieve urinary obstruction, not the entire gland, which misrepresents the surgical procedure's purpose.
B: You will have a nasogastric tube (NGT) left in place following this surgery. An NGT is not standard for TURP, which primarily involves the urinary system, negating the need for gastrointestinal intervention.
C: You will need to complete a bowel prep the night before this surgery. Bowel preparation is unnecessary for TURP, as the procedure focuses solely on the prostate and does not involve the digestive tract.
The nurse is teaching a client about consuming cranberry juice to prevent recurrent simple cystitis. The nurse understands that the treatment goal of consuming cranberry is to
Rationale:
C: Acidify the urine. Consuming cranberry juice helps prevent recurrent cystitis by acidifying the urine, creating an environment that inhibits the growth of bacteria responsible for urinary tract infections.
A: Increase the urine specific gravity. While urine specific gravity relates to concentration, cranberry juice primarily functions by altering urine acidity rather than affecting the specific gravity levels in urine.
B: Increase the urine leukocyte count. Cranberry juice does not target leukocyte count; its primary role is to provide an acidic environment that prevents bacterial adherence, rather than increasing immune response indicators.
D: Increase the protein in the urine. The consumption of cranberry juice does not contribute to protein levels in urine; its main purpose is to acidify urine, not influence protein concentrations.
The nurse is caring for a 68-year-old individual in the emergency department who had been on the bathroom floor for about 10 hours after a fall. While performing straight catheterization, the nurse notes that the urine output reaches 800 mL and continues to flow heavily. What action should the nurse take, and what is the rationale for this action?
Rationale:
Drain the client's bladder entirely and place a small amount in a urine specimen cup. This action is critical for assessing potential rhabdomyolysis, particularly given the prolonged immobilization and significant urine output indicating possible muscle breakdown.
B: Continue draining the bladder fully, then place a Foley catheter to monitor for sufficient urine output. This approach neglects the immediate need for diagnostic sampling to assess for underlying conditions.
C: Stop draining the client's bladder because the client is at risk for developing bladder spasms. This action disregards the necessity of fully assessing the urine output and potential complications from the fall.
D: Stop draining the client's bladder to prevent the risk of urinary tract infection (UTI) and notify the primary healthcare provider (PHCP) for further instructions. Halting drainage contradicts the urgency in evaluating the client's renal status and potential complications from the fall.
The nurse is teaching a group of students about fluids and electrolytes. It would be correct for the nurse to state that the role of calcium is to Select all that apply.
Rationale:
Calcium promotes blood clotting, increases bone density, promotes healthy dentition, and maintains neuromuscular health. These functions highlight calcium's critical role in various physiological processes essential for overall health.
D: regulate fluid balance. While calcium plays a role in some fluid regulation, it is not primarily responsible for maintaining fluid balance in the body.
The nurse is precepting a new graduate who will be caring for a client with bacterial cystitis. Which of the following statements by the new graduate requires follow-up?
Rationale:
A: The client should be counseled to increase their fluid intake. Encouraging fluid intake is beneficial for individuals with bacterial cystitis as it helps to flush out bacteria from the urinary tract.
C: Risk factors include frequent intercourse and douching. These activities can disrupt normal vaginal flora and introduce bacteria into the urinary tract, contributing to the development of cystitis.
D: Cranberry concentrate may be used to prevent future infections. Cranberry products are often recommended for their potential to prevent urinary tract infections by preventing bacterial adherence to the bladder wall.
The nurse is caring for a client with a phosphorus level of 5.3 mg/dL (1.71 mmol/L) [normal range: 3.0-4.5 mg/dL (0.97-1.45 mmol/L)]. The nurse identifies which of the following as possible causes of this condition? Select all that apply.
Rationale:
Tumor lysis syndrome, hypoparathyroidism, and renal failure can all lead to elevated phosphorus levels. These conditions disrupt normal phosphorus metabolism or excretion, resulting in increased serum phosphorus concentrations, as seen in the client’s lab results.
A: tumor lysis syndrome Rapid cell breakdown releases phosphorus into the bloodstream, causing elevated serum levels, consistent with the client's findings.
B: hypoparathyroidism Decreased parathyroid hormone levels lead to impaired phosphorus excretion, resulting in hyperphosphatemia, aligning with the client’s elevated phosphorus level.
C: hypercalcemia High calcium levels typically suppress phosphorus absorption and can lead to lower phosphorus levels, contradicting the client's elevated findings.
D: renal failure Impaired kidney function reduces phosphorus excretion, causing accumulation in the serum, which explains the client’s elevated phosphorus level.
E: anorexia Nutritional deficiencies from anorexia generally lead to decreased phosphorus levels, not the elevation seen in the client's lab results.
The nurse has taught a client about a scheduled intravenous (IV) urography (pyelogram). Which of the following statements by the client would indicate a correct understanding of the teaching?
Rationale:
B: I will take a laxative the night before to clear my bowels. This statement indicates a correct understanding since bowel preparation is often required prior to IV urography to ensure clear imaging of the urinary tract.
A: I should expect a temporary urinary catheter inserted during the procedure. A catheter is typically not necessary for IV urography, as the procedure focuses on imaging rather than direct access to the bladder.
C: I must fill my bladder with water immediately before the procedure. This statement misrepresents the protocol, as patients are generally advised to have a moderately full bladder, not to overfill it right before the imaging.
D: I may experience blood in my urine for a few days after this procedure. Although some bleeding can occur, it is not a guaranteed outcome and should not be expected for several days.
The nurse is administering IV magnesium to a client with a magnesium level of 1.5 mEq/L (0.62 mmol/L) [1.5-2.5 mEq/L, 0.6-1.2 mmol/L]. You check on them halfway through the infusion, and they report that their face feels flushed. What is the priority nursing intervention?
Rationale:
Slow down the infusion rate.
Flushing of the face is a common reaction to magnesium sulfate administration. Slowing the infusion allows for the assessment of the client's response and prevents potential adverse effects from rapid administration, ensuring patient safety while managing magnesium levels.
B: Notify the primary healthcare provider (PHCP) Immediate notification is unnecessary; the situation can be managed effectively by adjusting the infusion rate based on the client's current reaction and comfort.
C: Reassess the client when the infusion finishes. Delaying reassessment until the infusion completes may overlook potential complications and does not address the client's immediate discomfort or reactions during administration.
D: Stop the infusion. Halting the infusion may be premature; instead, adjusting the rate allows the client to continue receiving magnesium while managing side effects effectively, ensuring proper care.
The infection control nurse assesses clients at risk for a urinary tract infection (UTI). Which client is at the greatest risk of developing a UTI? A client with
Rationale:
A chronic indwelling urinary catheter receiving intravenous diuretics places the client at the greatest risk of developing a urinary tract infection (UTI). The catheter provides a direct pathway for bacteria, while diuretics can lead to urinary retention, increasing infection likelihood.
B: diabetes mellitus who is receiving intravenous antibiotics for a wound infection does present a risk for UTIs, but the antibiotics may help prevent infections during treatment.
C: obesity being treated for urge incontinence contributes to UTI risk, yet it does not inherently increase susceptibility as significantly as an indwelling catheter does.
D: a history of frequent bladder infections indicates a predisposition, but it does not guarantee immediate risk compared to the complications associated with an indwelling catheter.
The nurse is caring for an assigned client. Which prescription requires clarification with the primary healthcare provider (PHCP) based on the laboratory data?
Rationale:
C: ibuprofen
The prescription for ibuprofen requires clarification due to potential adverse effects on renal function, especially if laboratory data indicates compromised kidney function. This medication can exacerbate issues in patients with existing renal impairments.
A: furosemide
Furosemide is a diuretic typically used to manage fluid overload and does not generally necessitate clarification unless specific renal concerns are highlighted in the laboratory data.
B: vancomycin
Vancomycin is an antibiotic that may require monitoring for effectiveness and toxicity but does not inherently demand clarification unless specific lab results suggest significant renal impairment or infection resistance.
D: citalopram
Citalopram, an antidepressant, usually does not need clarification unless laboratory data indicates significant electrolyte imbalances that could affect safety and efficacy in the client’s treatment plan.
E: enalapril
Enalapril, an antihypertensive, typically requires no clarification unless the laboratory results indicate critical renal dysfunction or electrolyte abnormalities that could lead to adverse effects in the patient.
The nurse is assessing a client who was admitted four hours ago with hypomagnesemia. Which of the following findings should the nurse recognize as a common cause of hypomagnesemia? Select all that apply.
Rationale:
Hypomagnesemia can commonly result from alcoholism, anorexia nervosa, and diarrhea. These conditions lead to decreased magnesium intake or increased loss, significantly impacting magnesium levels in the body.
A: Renal failure This condition typically leads to hypermagnesemia due to reduced excretion, contrary to the low magnesium levels seen in hypomagnesemia.
E: Hypothyroidism While thyroid dysfunction can influence metabolism, it does not directly contribute to hypomagnesemia compared to the other listed conditions.
The nurse is caring for a client who has bacterial cystitis. The physician prescribes the client gentamicin. To prevent a complication associated with this medication, the nurse should monitor the client's?
Rationale:
B: creatinine. Monitoring creatinine levels is essential when administering gentamicin, as this antibiotic can cause nephrotoxicity. Assessing renal function helps ensure the medication does not adversely affect the client’s kidneys.
A: intake and output ratio. While monitoring intake and output is important in general nursing care, it does not specifically address the renal risks associated with gentamicin administration.
C: visual acuity. Gentamicin does not typically affect vision, making visual acuity monitoring irrelevant to its administration. This choice does not relate to the medication’s potential side effects.
D: fasting blood glucose. Fasting blood glucose levels are not pertinent when considering gentamicin therapy. This medication does not influence glucose metabolism or levels, rendering this option unrelated.
The nurse is teaching a class on acid-base imbalances. It would be correct for the nurse to identify which of the following would cause respiratory acidosis? Select all that apply.
Rationale:
Respiratory acidosis can be caused by pneumothorax and opioid overdose. These conditions lead to impaired gas exchange or respiratory depression, resulting in carbon dioxide accumulation and decreased blood pH.
A: Aspirin overdose leads to metabolic acidosis, not respiratory acidosis, due to its effects on metabolism and electrolyte balance rather than respiratory function.
D: Anxiety typically causes hyperventilation, which can lead to respiratory alkalosis instead of respiratory acidosis, as it decreases carbon dioxide levels in the blood.
E: Renal disease primarily affects metabolic acid-base balance rather than respiratory processes, thus not directly contributing to respiratory acidosis through lung function impairment.
The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern?
Rationale:
Headache and nausea are significant concerns following hemodialysis, as they may indicate complications such as fluid overload or electrolyte imbalances. These symptoms warrant immediate further evaluation to ensure the patient’s stability and safety post-treatment.
B: Scant blood on the AV fistula suggests minimal bleeding which is often manageable and not uncommon after dialysis. This finding typically does not indicate a critical condition requiring urgent intervention.
C: Potassium 3.7 mEq/L is within the normal range, indicating that the patient’s electrolyte levels are stable and not posing an immediate risk. This finding does not require further concern at this time.
D: Hemoglobin 8.8 g/dL indicates anemia, which is a concern but not as acute as immediate post-dialysis symptoms. Monitoring is essential, yet it does not demand urgent intervention like headache and nausea.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 4 of 6
History and Physical
A 57-year-old male client with stage three small cell lung cancer. The client had suddenly become disoriented and did not recognize his family members and relatives. He reports severe lower extremity weakness and has had three episodes of diarrhea in the past four hours. The client is undergoing 6 cycles of chemotherapy with cisplatin and etoposide. He is currently taking a 14-day course of 15 mg of prednisone. He is on his third day of steroid treatment. He has a medical history of dyslipidemia and advanced chronic obstructive pulmonary disease.
Laboratory Results
• Hemoglobin 14 g/dL [14-18 g/dL (140–180 g/L)]
• Hematocrit 42% (0.42) [42-52% (0.42-0.52)]
• White Blood Cell 11,000 mm3 [5-10 mm3]
• Platelet Count 140,000 mm3 [150-400 mm3 (150–400 × 109/L)]
• Glucose 139 mg/dL (7.72 mmol/L) [70–110 mg/dL (4-6 mmol/L)]
• Sodium 116 mEq/L [136–145 mEq/L (mmol/L)]
• Potassium 3.3 mEq/L [3.5–5.0 mEq/L (mmol/L)]
• Creatinine 0.7 mg/dL (61.88 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Blood Urea Nitrogen 8 mg/dL (2.86 mmol/L) [10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum Osmolality 277 mOsm/kg [285-295 mOsm/kg (285–295 mmol/kg)]
Nurses' Notes
0759: Client is completely disoriented and required maximum assistance to the stretcher because of unsteady gait. Lung sounds clear bilaterally. Alopecia noted. Skin is warm and dry and normal for ethnicity. Peripheral pulses 2+. No skin tenting. Hyperactive bowel sounds in all quadrants. 20-gauge peripheral vascular access device placed in the left antecubital space. T 97.8° F (36.6° C) P 88 RR 21 BP 123/68 Pulse oximetry reading 91% on room air.
0850: Verbal order was received from physician to insert indwelling urethral catheter.
0910: Urinary catheter inserted with sterile technique. 40 mL of dark yellow urine returned.
The physician diagnoses the client with syndrome of inappropriate antidiuretic hormone. The nurse updates the nurses' notes. For each potential order, click to specify whether the potential order is indicated or not indicated for the client.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
thiazide diuretic
B
continuous cardiac monitoring
C
seizure precautions
D
intravenous hypotonic fluids
E
urology consultation
F
desmopressin {DDAVP}
Rationale:
A: Not indicated. Thiazide diuretics can worsen hyponatremia, which the client is experiencing due to the syndrome of inappropriate antidiuretic hormone (SIADH). Management focuses on fluid restriction rather than diuretics.
B: Continuous cardiac monitoring is necessary given the client's disorientation, electrolyte imbalances, and potential arrhythmias from low sodium levels, ensuring prompt intervention if cardiac instability occurs.
C: Seizure precautions are warranted due to the significant risk of seizures associated with severe hyponatremia, which may lead to neurological complications and requires close monitoring for any seizure activity.
D: Intravenous hypotonic fluids would further dilute sodium levels, exacerbating hyponatremia and worsening the client’s condition. The treatment for SIADH should restrict fluids instead of adding hypotonic solutions.
E: Urology consultation is not required since the primary concern is the management of SIADH and electrolyte imbalances, not a urological issue that necessitates specialist input.
F: Desmopressin is contraindicated in SIADH, as it would increase water retention and worsen hyponatremia. The focus should be on managing fluid intake rather than administering additional antidiuretic hormone.
The nurse is teaching a client with hypercalcemia appropriate dietary measures. Which food selections by the client would require follow-up by the nurse? Select all that apply.
Rationale:
B: 2% milk 2% milk is high in calcium, which can exacerbate hypercalcemia. Dietary management for hypercalcemia requires limiting calcium-rich foods, making this choice inappropriate for the client's condition.
A: broccoli This vegetable is low in calcium and offers numerous health benefits, making it a suitable choice for someone managing hypercalcemia.
C: whole wheat pasta Whole wheat pasta contains minimal calcium, thus posing no significant risk to a client with hypercalcemia and can be included in a balanced diet.
D: bananas Bananas are low in calcium and provide potassium, which is beneficial for overall health, allowing them to be safely consumed by individuals with hypercalcemia.
E: seafood Many types of seafood are low in calcium, making them appropriate for individuals with hypercalcemia and contributing to a varied and healthy diet.
The following scenario applies to the next 1 items
The nurse in the medical-surgical unit is caring for a client following a transurethral resection of the prostate (TURP).
Item 1 of 1
Nurses’ Notes
1241: The client arrived at the medical-surgical unit six hours post-operative from a TURP. The client was alert and oriented to person, place, time, and situation. The client has a three-way indwelling urinary catheter and is continuously irrigated with isotonic saline. Urine output is ketchup-like with medium to large clots. The client reports the need to urinate and reported pressure in the pelvic region, described as spasms.
Intake and Output
Intake – Continuous bladder irrigation: 550 mL
Output – Indwelling catheter: 975 mL
Vital Signs
1257:
Blood Pressure 100/60 mm Hg
Temperature 98° F (36.7° C)
Heart rate 110/min
Respiratory rate 19 breaths per minute
Oxygen saturation 95% on room air
The client is demonstrating signs and symptoms of.
Rationale:
The client is demonstrating signs and symptoms of urinary catheter obstruction. The presence of ketchup-like urine with medium to large clots, along with reported pelvic pressure and spasms, indicates possible obstruction of the catheter.
B: hyponatremia The clinical data does not suggest any electrolyte imbalance; symptoms like confusion or seizures typically associated with hyponatremia are absent in this case.
C: shock Vital signs show a slightly low blood pressure and elevated heart rate, but without additional severe symptoms like altered mental status or significant hypotension, shock is unlikely.
D: urinary tract infection The symptoms presented do not include fever, dysuria, or increased urgency typical of a urinary tract infection, making this diagnosis less likely in the context provided.
The nurse preceptor is orienting a newly hired nurse caring for a client with advanced polycystic kidney disease (PKD). Which of the following actions by the newly hired nurse would require follow-up by the nurse preceptor?
Rationale:
Requesting a prescription for ketorolac to help relieve the client's pain. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can cause renal complications, especially in patients with advanced polycystic kidney disease, necessitating cautious evaluation before use.
B: Instructing the client on how to use guided imagery as a comfort strategy. This action promotes relaxation and pain management, making it a suitable approach for the client's care.
C: Applying dry heat to the client's abdomen or flank for pain relief. While heat can alleviate discomfort, it may not address the underlying issues associated with advanced PKD effectively.
D: Provides the client with foods high in fiber and low in salt. A diet low in salt is beneficial, yet focusing solely on fiber without addressing protein and potassium is insufficient for managing PKD.
The nurse is caring for a client in the medical-surgical unit. The nurse is reviewing the client's laboratory data and should take which action.
Rationale:
Review the client's current medications.
Evaluating the client’s medications is crucial to identify potential interactions or side effects that may affect their laboratory results. Understanding these factors enables the nurse to provide safe and effective care tailored to the client's specific needs and health status.
B: Plan to initiate daily fluid restrictions. Fluid restrictions are not indicated without further assessment of the client's condition and specific laboratory values that warrant such actions.
C: Clarify the prescribed chest radiograph (x-ray). Clarifying the x-ray order does not address the immediate need to understand how medications may influence the client's health status and treatment plan.
D: Insert an indwelling urinary catheter to monitor urinary output. Inserting a catheter should only be considered when there is clear evidence of need, not as a default action without prior assessment.
The nurse is performing a continuing education program about fluid and electrolytes. It would be appropriate for the nurse to reinforce that which intravenous (IV) solution is hypertonic? Select all that apply.
Rationale:
3% saline, Dextrose 10% in water (D10W), and 5% Dextrose with 0.45% Sodium Chloride are hypertonic solutions.
These solutions have higher osmolarity compared to blood plasma, leading to fluid shifting from cells into the extracellular space, which is essential for managing certain medical conditions and maintaining fluid balance in patients.
D: Lactated Ringers (LR) This solution is isotonic, containing electrolytes that closely mimic plasma, making it suitable for fluid resuscitation without causing cellular dehydration.
E: 0.45% Sodium Chloride (0.45% NaCl) This solution is hypotonic, promoting fluid movement into cells rather than out, which can lead to cellular swelling and potentially harmful effects.
The following scenario applies to the next 1 items
The nurse in the medical-surgical unit is caring for a client.
Item 1 of 1
Progress Notes
Day 1
1700: Admitted from the emergency department with a small bowel obstruction. Nasogastric tube (NGT) was inserted with intermittent suction. Awaiting surgical consult.
Day 2
0900: Morning labs reviewed and orders were given. Still awaiting surgical consult.
Orders
Day 1:
• Insert nasogastric tube to low intermittent suction
• Insert a peripheral vascular access device
• nothing by mouth (n.p.o.) status
• consult surgery for evaluation
• continuous infusion of 0.9% sodium chloride (normal saline) 100 mL/hr
Day 2:
• potassium chloride 40 mEq via intravenous piggy-back x 1 dose
The nurse reviews the clinical data. The nurse prepares to implement the orders from day 2. Complete the following sentences by choosing from the list of options. Prior to the nurse administering the prescribed IV potassium, the nurse should....... The nurse should also.......... The nurse should infuse the IV potassium over. During the infusion, if the client should report pain at the vascular access device, the nurse should......
Rationale:
The nurse should ensure the client has adequate urine output. Maintaining sufficient urine output is crucial when administering potassium, as it helps prevent hyperkalemia and monitors renal function during the infusion.
B: implement seizure precautions. This measure is not immediately relevant for potassium administration, as the primary focus is on monitoring renal function and electrolyte balance during the infusion.
D: 2 hours. Administering potassium intravenously requires careful monitoring, and it is typically infused over a longer duration to prevent complications, making this option unsuitable.
G: apply a warm compress to the vascular access device. While warmth can alleviate discomfort, it does not address the critical need to monitor for potential complications directly related to potassium infusion.
The nurse is teaching a client about the newly prescribed medication, sevelamer. Which statement, if made by the client, would indicate a correct understanding of the teaching?
Rationale:
C: I should take this medication with my meal. Sevelamer is designed to be taken with meals to effectively bind phosphate in the gastrointestinal tract, thus improving its absorption and efficacy.
A: My blood pressure may increase while I take this medication. Sevelamer does not typically influence blood pressure levels, as its primary function is to manage phosphate levels, not cardiovascular effects.
B: This medication will help lower my calcium level. Sevelamer primarily targets phosphate levels rather than calcium, making this statement misleading regarding its function and intended therapeutic outcome.
D: I may experience bad diarrhea with this medication. Although gastrointestinal side effects can occur, bad diarrhea is not a guaranteed outcome and varies greatly among individuals taking sevelamer.
The nurse reviews a client's laboratory data. Which laboratory data requires follow-up?
Rationale:
Laboratory data requiring follow-up include potassium, calcium, BUN, and creatinine levels due to potential implications for renal function and electrolyte balance, which are critical in patient care management.
A: Sodium Normal sodium levels typically do not necessitate immediate follow-up unless accompanied by other abnormal findings, indicating stability in electrolyte status within the typical range.
C: Calcium While calcium levels can indicate metabolic issues, they do not always require immediate follow-up unless they are significantly abnormal or symptomatic, which is not specified here.
D: BUN Although BUN can indicate hydration status or renal function, it generally requires follow-up only if it is markedly elevated or paired with symptoms indicating renal distress.
E: Creatinine Similar to BUN, creatinine levels warrant attention primarily when they show significant deviation from normal ranges, not necessarily indicating urgent follow-up without other concerning data present.
A client with benign prostatic hyperplasia (BPH) is post-operative following transurethral resection of the prostate (TURP) and is now receiving continuous bladder irrigation. Upon assessment, the nurse notes that the output from the urinary catheter has stopped. Which nursing intervention is most appropriate?
Rationale:
Attempt to dislodge a clot. This intervention is appropriate because post-operative patients with TURP often experience clot formation, leading to urinary obstruction. Dislodging the clot can restore normal urinary flow and prevent complications.
A: Reinsert a new catheter. This option may not address the immediate issue of obstruction caused by a clot and could complicate the situation further.
B: Increase the infusion rate of the irrigation. This action might not resolve the underlying problem of a clot and could lead to overdistension of the bladder.
D: Contact the health care provider (HCP). While this may be necessary if other interventions fail, immediate action to dislodge the clot is more critical in this scenario.
A client was admitted to the emergency department due to low serum calcium levels. Upon further examination, the client demonstrates carpopedal spasms and reports numbness in their lips and hands. An ECG revealed a prolonged QT interval. Based on this information, the nurse should suspect which condition?
Rationale:
Hypoparathyroidism. The signs of low serum calcium, carpopedal spasms, and numbness alongside a prolonged QT interval indicate inadequate parathyroid hormone levels, leading to hypocalcemia and associated neuromuscular symptoms typical of hypoparathyroidism.
A: Hyperthyroidism. This condition primarily affects metabolism and does not typically present with the neuromuscular symptoms or electrolyte imbalances seen in this client’s case.
B: Hypothyroidism. Although it can cause various symptoms, it does not directly relate to low serum calcium levels or neuromuscular issues like those demonstrated here.
C: Hyperparathyroidism. Elevated parathyroid hormone levels associated with this condition usually result in hypercalcemia, contradicting the low calcium levels observed in the client’s examination.
The nurse cares for a client with a potassium of 3.1 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The primary healthcare provider (PHCP) prescribed 40 mEq of intravenous (IV) potassium over four hours. Which assessment finding would indicate a therapeutic effect?
Rationale:
A: normoactive bowel sounds Normal bowel sounds do not specifically indicate an increase in potassium levels and are not a reliable marker for assessing the therapeutic effect of potassium replacement therapy.
B: flattened T-waves A therapeutic effect of potassium supplementation is reflected by the normalization of T-wave morphology on an ECG, indicating improved cardiac function and electrolyte balance.
C: reduced deep tendon reflexes Diminished deep tendon reflexes are indicative of hypokalemia rather than a therapeutic effect, as low potassium levels can impair neuromuscular function and reflex activity.
D: muscle cramping Muscle cramping is a symptom associated with low potassium levels; thus, its presence suggests a lack of therapeutic effect from the potassium treatment rather than improvement.
The nurse is caring for a client who was newly prescribed warfarin. Which medication on the client's medication list requires follow-up with the primary healthcare provider (PHCP)?
Rationale:
B: Saw Palmetto may interact with warfarin, potentially increasing the risk of bleeding. This herbal supplement can affect blood clotting mechanisms, necessitating a follow-up with the primary healthcare provider to ensure patient safety and appropriate management of anticoagulation therapy.
A: Loratadine does not have significant interactions with warfarin, making it a safe option for allergy relief in patients on anticoagulation therapy.
C: Furosemide, a diuretic, does not significantly affect warfarin's anticoagulant effects and is commonly prescribed alongside it for fluid management.
D: Pantoprazole, a proton pump inhibitor, has no major interactions with warfarin and is often used to treat gastrointestinal issues without impacting coagulation.
A client experiencing an acute exacerbation of ulcerative colitis underwent diagnostic testing and was found to have elevated serum osmolality and urine specific gravity. Which of the following is related to these findings?
Rationale:
Deficient fluid volume. Elevated serum osmolality and urine specific gravity indicate dehydration and fluid loss, commonly seen during an acute exacerbation of ulcerative colitis, where inflammation leads to increased stool output and fluid depletion.
A: Renal insufficiency. This condition typically presents with altered electrolyte balance and does not directly relate to elevated serum osmolality and urine specific gravity in the context of ulcerative colitis.
B: Diabetes insipidus. Characterized by excessive urination and thirst, it does not correlate with the acute exacerbation of ulcerative colitis or the specific findings presented in this case.
C: Hypoaldosteronism. While it may affect fluid balance, it does not align with the acute symptoms of ulcerative colitis or the specific diagnostic findings of elevated osmolality and urine gravity.
The nurse is caring for a client with end-stage renal disease who receives prescribed sevelamer. Which of the following findings would indicate a therapeutic response?
Rationale:
Decreased serum phosphorus levels indicate a therapeutic response to sevelamer. This medication effectively binds to phosphorus in the gastrointestinal tract, thus reducing its absorption and helping to manage hyperphosphatemia common in end-stage renal disease patients.
A: Decreased serum calcium levels High sevelamer use does not directly lead to reduced calcium; it primarily targets phosphorus levels without significantly affecting calcium homeostasis in the bloodstream.
B: Increased hemoglobin and hematocrit Sevelamer does not influence hemoglobin or hematocrit levels. These values are more closely associated with erythropoiesis and iron status rather than phosphorus management.
C: Decreased serum potassium levels Sevelamer's primary function is to lower serum phosphorus, not potassium. Potassium levels are regulated through different mechanisms and not directly impacted by this medication.
The nurse is assessing assigned clients. Which client has a risk for urinary retention? Select all that apply.
Rationale:
A 78-year-old man diagnosed with an enlarged prostate, a 75-year-old woman with vaginal prolapse, an 89-year-old man with dementia, a 73-year-old woman on antihistamines, and a 90-year-old man with difficulty walking to the restroom are at risk for urinary retention.
The enlarged prostate can obstruct urine flow, while vaginal prolapse and dementia can impair bladder control. Antihistamines may cause retention, and mobility issues hinder access to the restroom.
B: An 83-year-old woman on bed rest. Limited mobility may contribute to other issues, but bed rest alone doesn't inherently increase urinary retention risk without other contributing factors.
The nurse is assessing a client with an acute kidney injury (AKI). Which of the following findings would support a diagnosis of AKI?
Rationale:
Oliguria. This finding indicates a significant reduction in urine output, which is a hallmark of acute kidney injury (AKI). Oliguria reflects the kidneys' impaired ability to filter and excrete waste, supporting the AKI diagnosis.
A: hypernatremia Elevated sodium levels may relate to other conditions and do not specifically indicate kidney impairment. AKI is characterized more by changes in urine output than by sodium concentration.
B: metabolic alkalosis This condition arises from various factors such as vomiting or diuretics, rather than directly linking to acute kidney injury. AKI typically presents with metabolic acidosis instead.
D: hypokalemia Low potassium levels can occur due to various reasons unrelated to kidney function. AKI is often associated with hyperkalemia, not hypokalemia, making this option misleading.
Which of the following anticholinergics does the nurse recognize as appropriate for a patient diagnosed with urinary bladder urgency and incontinence?
Rationale:
Oxybutynin is appropriate for a patient diagnosed with urinary bladder urgency and incontinence. It specifically targets the bladder's muscarinic receptors, reducing involuntary contractions and alleviating symptoms of urgency and frequency effectively.
A: Dicyclomine primarily treats gastrointestinal disorders and does not address bladder-related issues, making it unsuitable for urinary urgency and incontinence management.
B: Ipratropium is indicated for respiratory conditions and does not have a role in managing urinary symptoms, thus failing to provide the necessary relief for bladder urgency.
D: Scopolamine, while an anticholinergic, is primarily used for motion sickness and does not effectively target bladder function, rendering it ineffective for urinary urgency and incontinence.
The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PHCP)?
Rationale:
A: WBC 19,000 mm3 [5,000-10,000 mm3] A white blood cell count of 19,000 mm3 indicates a potential infection or inflammation, which is critical to address promptly in a client undergoing peritoneal dialysis to prevent serious complications.
B: Hemoglobin 9 g/dL [Male: 14-18 g/dL (140-180 g/L) Female: 12-16 g/dL (120-160 g/L)] While low hemoglobin levels indicate anemia, they do not require immediate reporting like elevated white blood cell counts do.
C: Calcium 8.6 mg/dL [9.0-10.5 mg/dL] This calcium level is slightly low but typically does not necessitate urgent attention, especially compared to signs of potential infection indicated by elevated white blood cells.
D: Serum pH 7.33 [7.35-7.45] A serum pH of 7.33 indicates acidosis, which is concerning, but it is less urgent than addressing a significantly elevated white blood cell count signaling infection.
The nurse is caring for a client whose latest lab results show a serum calcium level of 13.2 mg/dL (3.3 mmol/L) [9-10.5 mg/dL, 2.12-2.52 mmol/L]. Which medication does the nurse expect to administer based on this lab result? Select all that apply.
Rationale:
Calcitonin and IV Bisphosphonates are the expected medications to administer for a client with a serum calcium level of 13.2 mg/dL.
Calcitonin helps lower elevated serum calcium levels by inhibiting osteoclast activity and enhancing renal excretion of calcium. IV Bisphosphonates also effectively reduce calcium levels by preventing bone resorption, both critical in managing hypercalcemia.
A: Phosphorus Supplementing phosphorus does not directly address hypercalcemia and may exacerbate calcium levels instead, making it unsuitable for this clinical scenario.
C: Vitamin D This medication increases calcium absorption in the gut, which could worsen hypercalcemia and is contraindicated in patients with elevated serum calcium levels.
D: IV calcium gluconate Administering additional calcium in the presence of hypercalcemia is counterproductive, as it would further elevate serum calcium levels rather than reduce them.
The oncoming nurse learns that her new patient is suffering from Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion. Which of the following nursing actions is the most important?
Rationale:
Assess the patient's mental status.
Monitoring mental status is critical in SIADH as sodium levels can drop, leading to confusion, seizures, or coma. Early detection of neurological changes allows for timely interventions, preventing serious complications and ensuring patient safety.
B: Provide oral hygiene. Maintaining oral hygiene is beneficial but does not address the immediate risks associated with SIADH, where neurological assessment is vital for patient safety.
C: Keep accurate intake and output measurements. While tracking fluid balance is important, it does not directly assess the patient's neurological condition, which is crucial in managing SIADH effectively.
D: Reduce stress and discomfort. Reducing stress is helpful for overall well-being but does not prioritize the urgent need to monitor mental status, which is essential in SIADH management.
The nurse is caring for a client who is severely hypernatremic. The nurse should prioritize assessing the client's
Rationale:
The client’s neurological status should be prioritized. Severe hypernatremia can lead to significant neurological complications, including confusion, seizures, and coma, necessitating close monitoring of brain function and responsiveness.
A: cardiovascular status. While hypernatremia can influence cardiovascular health, the most immediate risks pertain to neurological effects rather than cardiac issues, which are secondary concerns in this context.
B: genitourinary status. Although fluid balance is important, genitourinary assessment does not directly address the critical neurological impacts of severe hypernatremia, making it a lower priority in this situation.
D: gastrointestinal status. Gastrointestinal symptoms may occur with hypernatremia, yet the primary risks focus on neurological impairment, which demands more urgent assessment and intervention compared to gastrointestinal concerns.