The nurse receives a prescription for sevelamer. The nurse plans on administering this medication
Rationale:
Sevelamer should be administered with the client's meals. This timing enhances the medication's efficacy by binding dietary phosphate, helping to control hyperphosphatemia in patients with chronic kidney disease during food intake.
B: immediately before hemodialysis. Administering sevelamer right before hemodialysis does not align with its purpose of managing phosphate levels during meals, rendering it ineffective in that context.
C: with a prescribed proton pump inhibitor (PPI). Co-administering sevelamer with a PPI can alter its absorption and effectiveness, which diminishes the intended therapeutic benefits of phosphate control.
D: right before the client goes to bed. Taking sevelamer at bedtime fails to maximize its phosphate-binding action during meals, which is crucial for managing dietary phosphate intake effectively.
The nurse is reviewing labs for a client with a serum potassium level of 3.3 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The nurse should take which essential action based on this laboratory result?
Rationale:
Educating the client on potassium-rich foods is essential to address the low serum potassium level of 3.3 mEq/L. This action helps promote dietary changes that can increase potassium levels and support overall health.
B: Implement continuous telemetry monitoring. While monitoring might be necessary, the immediate action should focus on dietary adjustments rather than surveillance alone.
C: Obtain an order for calcium gluconate. Calcium gluconate is used for hyperkalemia, not hypokalemia, making it an inappropriate intervention for a low potassium level.
D: Assess the client's neurological status. Although assessment is important, prioritizing education on potassium intake directly addresses the underlying issue of low serum potassium levels.
The nurse is caring for a client with nephrotic syndrome. Which of the following assessment findings would be expected? Select all that apply.
Rationale:
Proteinuria, hypoalbuminemia, and edema are expected findings in nephrotic syndrome due to increased permeability of the glomeruli, leading to significant protein loss and resultant fluid retention and low serum albumin levels.
D: Hyperglycemia High blood sugar levels are not typically associated with nephrotic syndrome, as it primarily involves kidney function and protein loss rather than glucose metabolism alterations.
E: Jaundice Yellowing of the skin indicates liver dysfunction or hemolysis, which does not correlate with nephrotic syndrome, a condition mainly affecting renal processes rather than hepatic issues.
Which of the following signs and symptoms may lead the nurse to suspect hypovolemia? Select all that apply.
Rationale:
Decreased skin turgor, dry mucous membranes, and low blood pressure are signs indicating hypovolemia, as they reflect reduced fluid volume and impaired hydration, leading to physiological changes in the body.
B: Increased urine output indicates effective kidney function and fluid excretion, which does not suggest hypovolemia. In fact, it may imply the opposite, such as adequate hydration.
D: Weight gain typically signifies fluid retention or excess intake. This does not align with hypovolemia, where fluid loss leads to weight decrease rather than an increase.
The nurse is reviewing the client's laboratory data. Which current prescription should the nurse clarify with the primary healthcare provider (PHCP)?
Rationale:
C: naproxen. The nurse should clarify the prescription for naproxen because it can increase the risk of renal impairment, particularly in individuals with existing kidney issues or who are on diuretics.
A: hydrochlorothiazide This medication is commonly used for hypertension and can be appropriate, especially if the client has fluid retention or high blood pressure.
B: lisinopril Lisinopril is an ACE inhibitor effective for hypertension and heart failure, making it a suitable option for many patients without contraindications.
D: tamsulosin Tamsulosin is indicated for benign prostatic hyperplasia and generally does not pose significant risks that warrant clarification in laboratory contexts.
The nurse is administering phosphate excreting medications to a client with hypocalcemia. The reason for administering this medication is because
Rationale:
When serum phosphorus decreases, serum calcium increases. This relationship is critical in managing hypocalcemia, as lowering phosphorus levels can help restore calcium balance, thereby alleviating the client’s condition effectively.
A: as phosphorus exits the body so does calcium. This statement oversimplifies the relationship; calcium does not directly exit with phosphorus, making it an inaccurate representation of physiological interactions.
B: calcium is managed by the excretion of phosphorus. This suggests a direct management system that does not exist; calcium levels are influenced by various factors beyond just phosphorus excretion.
D: phosphorus must be above 4.5 mg/dL (1.45 mmol/L) before calcium can increase. This presents a false threshold; serum calcium can increase independently of phosphorus levels, debunking this assertion.
The nurse is caring for a client with hypokalemia scheduled to receive the prescribed 20 mEq of intravenous (IV) potassium. Which client assessment requires notification of the primary healthcare provider (PHCP)?
Rationale:
Oliguria
Oliguria indicates reduced urine output, which can signify potential renal impairment or hyperkalemia risk when administering potassium. This assessment necessitates immediate communication with the primary healthcare provider to prevent serious complications related to potassium administration and ensure safe management of the client's hypokalemia.
B: Abdominal distention This symptom may suggest gastrointestinal issues, but does not directly indicate a risk associated with potassium infusion, making it less urgent than renal function concerns.
C: Muscle weakness While muscle weakness can relate to hypokalemia, it does not indicate an immediate risk during potassium administration, allowing for continued monitoring without urgent intervention.
D: Weak peripheral pulses This finding can indicate circulatory issues but does not specifically demand immediate notification regarding potassium administration, as other factors may be contributing to this assessment.
The nurse is caring for a client with a kidney injury with a serum potassium level of 6.1 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. Which of the following actions is a priority?
Rationale:
C: Place the client on a cardiac monitor. Monitoring cardiac status is crucial due to the elevated potassium level of 6.1 mEq/L, which poses a significant risk for life-threatening arrhythmias and requires immediate intervention.
A: Obtain a prescription for a diuretic to increase urine output. While diuretics can help reduce potassium levels, they are not the immediate priority in this critical situation.
B: Check the client's sodium level. Sodium levels are important for overall electrolyte balance, but they are not the immediate concern when managing severe hyperkalemia and its cardiac implications.
D: Encourage oral fluid intake. Increasing fluid intake may help with potassium excretion, but it does not address the urgent risk of cardiac complications associated with hyperkalemia.
The client is diagnosed with acute kidney failure. Which of the following is an appropriate psychosocial problem for the nurse to include in the care plan?
Rationale:
Anxiety related to the disease process and uncertainty of prognosis. This option addresses the emotional impact of acute kidney failure, recognizing that clients often experience fear and stress about their health and future outcomes, which are critical to incorporate in the care plan.
A: Imbalanced nutrition: less than body requirements related to altered metabolic state and dietary restrictions. This focuses on physical needs and does not adequately address the emotional and psychological aspects of the client's experience.
C: Excess fluid volume related to compromised regulatory mechanisms secondary to acute renal failure. This option pertains to a physiological condition, overlooking the psychological ramifications and emotional support necessary for the client's mental health.
D: Risk for infection related to invasive procedures and an altered immune response secondary to renal failure. This highlights a medical concern but fails to consider the anxiety and emotional distress that often accompany serious health issues.
The nurse is working with a client who has been diagnosed with hypervolemia. Which of the following conditions can cause hypervolemia? Select all that apply.
Rationale:
Heart failure, renal failure, and hormonal imbalances can all lead to hypervolemia due to their effects on fluid retention and regulation in the body, causing an excess of blood volume.
C: Type 1 Diabetes Mellitus This condition primarily affects blood sugar regulation and does not directly contribute to fluid overload in the body.
D: Third degree burns While significant fluid loss occurs in severe burns, it typically results in hypovolemia rather than hypervolemia due to dehydration and fluid shifts.
The nurse is caring for a client on a medical floor. The nurse would recognize that which diagnosis increases the client's risk of developing hyperkalemia?
Rationale:
Acute renal failure significantly increases the risk of developing hyperkalemia due to the kidneys' reduced ability to excrete potassium. This impairment leads to potassium accumulation in the bloodstream, resulting in hyperkalemia.
A: Cushing's syndrome Excess cortisol production can lead to potassium loss, decreasing the likelihood of hyperkalemia despite affecting electrolyte balance in the body.
C: Cystic fibrosis While cystic fibrosis impacts various systems, it does not directly increase potassium levels or the risk of hyperkalemia in affected individuals.
D: Bulimia nervosa This eating disorder typically involves electrolyte imbalances due to purging behaviors, but it does not specifically elevate potassium levels or predispose individuals to hyperkalemia.
The nurse is preparing a client for a renal ultrasound. Which of the following statements accurately describes the purpose of this procedure?
Rationale:
It evaluates the size, shape, and location of the kidneys, as well as blood flow to the kidneys.
This statement accurately represents the purpose of a renal ultrasound, which primarily assesses kidney anatomy and vascularity, helping to identify abnormalities or conditions affecting renal health. This imaging technique provides essential information for diagnosis and treatment planning related to renal function and structure.
A: It measures the concentration of potassium and sodium in the blood. This procedure focuses on blood chemistry analysis, which is unrelated to the imaging objectives of a renal ultrasound.
B: It evaluates the function of the kidneys in producing red blood cells. While kidneys play a role in erythropoiesis, a renal ultrasound does not assess this function directly, focusing instead on anatomical features.
D: It detects abnormal levels of urea in the bloodstream. This statement pertains to blood tests for kidney function rather than the imaging capabilities of a renal ultrasound, which does not measure biochemical levels.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 78-year-old female client
Item 1 of 1
Nurses' Note
1355: Client was brought to the ED by the client's adult children, who reported that while she was visiting, she reported dizziness and seemed slightly confused. The adult child reports that the symptoms started one day ago. The client recently had a change in her blood pressure medication, with the physician increasing the dosage of her prescribed furosemide. Medical history of hypertension, hyperlipidemia, and osteoarthritis. Vital signs: T 100° F (37.8° C), P 104, RR 22, BP 110/66, pulse oximetry reading 95% on room air.
On assessment, the client is lethargic and oriented to person and place, but not time. The client's breathing appears unlabored with tachypnea. Clear lung sounds throughout all lung fields. Skin is warm, dry, and flaky. Peripheral pulses 1+ in all extremities. Aching pain reported in the hips and knees and rated 5 on a scale of 0 (no pain) to 10 (severe pain). Client was ambulated to the bathroom, where she urinated 300 mL of clear, yellow urine without any odor or particulates. 22-gauge peripheral venous access device (VAD) placed in right forearm.
Complete the sentence below by choosing from the list of options. Based on the client's..... and............. this client is at highest risk for........
Rationale:
Based on the client's vital signs and dosage increase of diuretic, this client is at highest risk for fluid volume deficit. The elevated pulse rate and low blood pressure indicate potential dehydration, compounded by the increased furosemide dosage, which promotes diuresis. These factors combined suggest a significant risk for fluid imbalance in this elderly patient.
A: lung sounds. Lung sounds being clear does not indicate any respiratory issues or fluid overload, which makes this option irrelevant to the risk of fluid volume deficit.
C: pain level. While the client reports pain, it does not correlate with the risk factors related to fluid volume deficit or the recent medication changes affecting hydration status.
E: urinary infection. The clear, yellow urine without odor or particulates suggests no signs of infection, making this option inconsistent with the client's presentation and current medical concerns.
Which nursing intervention would be a priority for a patient receiving 3% saline maintenance fluids?
Rationale:
Assess blood pressure. Maintaining hemodynamic stability is crucial for patients receiving 3% saline maintenance fluids, as this hypertonic solution can lead to fluid overload and alterations in blood pressure, necessitating close monitoring.
A: Monitor serum HCO3- Evaluating bicarbonate levels is less critical than blood pressure assessment, as the primary concern with 3% saline is fluid balance and hemodynamic status rather than acid-base balance.
B: Monitor urine sodium Tracking urine sodium levels does not provide immediate insight into the patient's hemodynamic status, which is paramount when administering hypertonic saline solutions that can impact fluid distribution.
D: Collect 24-hour urine output While monitoring urine output is important, it does not directly address potential fluctuations in blood pressure that can occur with the administration of hypertonic saline solutions.
The nurse is caring for a client who prescribed a 40 mEq potassium chloride capsule for hypokalemia. The client reports difficulty swallowing capsules. Which action should the nurse take when administering this medication?
Rationale:
Sprinkle the contents of the capsule onto a spoonful of soft food. This method allows for easier ingestion while ensuring that the client receives the full dosage of potassium chloride, minimizing the risk of choking and promoting safe administration.
B: Have the client chew the capsule prior to swallowing. Chewing the capsule could alter the medication's effectiveness, as it is designed for delivery in its intact form for proper absorption.
C: Sprinkle the contents of the capsule into a cup of warm water. Dissolving the medication in water may lead to uneven distribution, affecting dosage accuracy and potentially causing gastrointestinal discomfort.
D: Put the capsule under the client's tongue and have it dissolve. Sublingual administration is inappropriate for this medication, as potassium chloride requires proper gastrointestinal absorption rather than absorption through the oral mucosa.
The nurse is teaching a group of students a potential cause of metabolic alkalosis. It would indicate a correct understanding if a student stated which condition could cause this acid-base imbalance?
Rationale:
Excessive vomiting can lead to metabolic alkalosis due to the loss of stomach acid, which contains hydrochloric acid. This loss results in an increased concentration of bicarbonate in the blood, creating an alkaline environment.
A: Hyperventilation causes respiratory alkalosis by reducing carbon dioxide levels, not metabolic alkalosis, thus failing to align with the acid-base imbalance described in the question.
B: Urinary retention does not directly influence acid-base balance. It primarily affects fluid and electrolyte management rather than leading to metabolic alkalosis specifically through acid loss.
C: Opioid toxicity typically results in respiratory depression, which may lead to respiratory acidosis, not metabolic alkalosis, as it does not involve the loss of gastric acid or raise bicarbonate levels.
The nurse is caring for a client with polycystic kidney disease (PKD). Which of the following would indicate the client is achieving treatment goals?
Rationale:
Blood Pressure 128/63 mmHg indicates the client is achieving treatment goals. Maintaining blood pressure within a normal range is crucial for managing polycystic kidney disease, as it reduces the risk of complications and preserves kidney function.
B: Creatinine 2.3 mg/dL indicates impaired kidney function, as normal levels should be lower, suggesting that treatment goals are not being met.
C: Proteinuria 2+ signifies ongoing protein leakage into urine, reflecting kidney damage and indicating that the therapeutic objectives are not satisfactorily addressed.
D: Sodium 132 mEq/L shows hyponatremia, which can lead to serious complications, indicating that the client's treatment goals are not being fulfilled effectively.
The following scenario applies to the next 6 items.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 2 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.
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.
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)]
The nurse focuses on the client's serum sodium level and recognizes which conditions may cause hyponatremia or hypernatremia. For each condition below, click to specify if it causes hyponatremia or hypernatremia.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
syndrome of inappropriate antidiuretic hormone (SIADH)
B
diabetes insipidus (DI)
C
adrenal insufficiency
D
Cushing's syndrome
Rationale:
Hyponatremia. The syndrome of inappropriate antidiuretic hormone (SIADH) leads to water retention, diluting sodium levels in the serum and causing hyponatremia, particularly in patients with underlying conditions like cancer or lung disease.
B: Diabetes insipidus (DI) causes hypernatremia due to excessive water loss, resulting in concentrated serum sodium levels as the kidneys fail to retain water effectively.
C: Adrenal insufficiency contributes to hyponatremia by reducing aldosterone production, which impairs sodium reabsorption, leading to sodium loss in the urine.
D: Cushing's syndrome triggers hypernatremia from elevated cortisol levels, which promote sodium retention and increased blood volume, raising serum sodium concentrations.
The nurse is caring for a client with a sodium level of 130 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which of the following medications may cause this abnormality? Select all that apply.
Rationale:
Spironolactone and tolvaptan can lead to hyponatremia. Hydrochlorothiazide, a thiazide diuretic, increases sodium excretion, while tolvaptan inhibits vasopressin, leading to decreased water reabsorption and increased sodium levels.
A: Spironolactone This medication typically causes hyperkalemia, not hyponatremia, by inhibiting aldosterone, which leads to sodium retention and potassium excretion.
C: Prednisone Corticosteroids like prednisone can cause fluid retention and possible hypernatremia rather than hyponatremia, affecting sodium balance differently.
D: Sodium polystyrene This agent is used to treat hyperkalemia and does not significantly influence sodium levels, making it unlikely to cause hyponatremia.
The nurse is providing discharge instructions to a client prescribed phenazopyridine. Which of the following instructions should the nurse include?
Rationale:
Urine may have a reddish or orange coloration after taking this medication. This is a known side effect of phenazopyridine, which is used to relieve urinary tract discomfort and can cause noticeable changes in urine color.
A: Discontinue this medication if urinary discoloration occurs. This option misrepresents the expected side effect, as discoloration is typical and not a reason to stop the medication.
B: Take this medication on an empty stomach. This recommendation is inaccurate; phenazopyridine can be taken with food to minimize gastrointestinal upset, contrary to this suggestion.
C: This medication may increase the amount of urine you produce. Phenazopyridine does not function as a diuretic, so it does not have any effect on urine production volume.
The following scenario applies to the next 6 items.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 1 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.
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.
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)]
Which of the following assessment findings require immediate follow-up? Select all that apply.
Rationale:
Disorientation and altered mental status necessitate immediate follow-up. Additionally, severely low sodium (116 mEq/L) and potassium (3.3 mEq/L) levels, along with elevated glucose (139 mg/dL), suggest critical imbalances that require urgent intervention to prevent further complications in this already vulnerable patient.
B: reports of diarrhea Severe diarrhea is concerning but not immediately life-threatening; it requires monitoring and management rather than urgent follow-up.
E: white blood cell count A WBC count of 11,000 mm3 indicates mild leukocytosis, likely related to the cancer or infection, but does not require immediate action.
G: alopecia While alopecia is significant for the patient undergoing chemotherapy, it does not pose an immediate risk to health and does not necessitate urgent follow-up.
The nurse is placing a client with chronic kidney disease on a cardiac monitor. What is the reason for this action?
Rationale:
B: Hyperkalemia may result in dysrhythmias. Clients with chronic kidney disease often have elevated potassium levels due to impaired renal function, which can lead to dangerous heart rhythm disturbances, necessitating continuous cardiac monitoring.
A: Clients with chronic kidney disease are prone to hypertension. While hypertension is common in these patients, it does not directly explain the necessity of cardiac monitoring over the risk of dysrhythmias.
C: Cardiac monitoring is necessary to evaluate the need for hemodialysis. Monitoring does not specifically assess hemodialysis needs; it primarily focuses on immediate cardiac rhythm changes related to electrolyte imbalances.
D: Clients with chronic kidney disease may experience false episodes of asystole. While some may misinterpret heart rhythms, this does not justify the primary reason for monitoring cardiac activity in these patients.
The following scenario applies to the next 1 items
The medical-surgical nurse is caring for a 67-year-old client
Item 1 of 1
Nurses’ Note
1535: Client returned from hemodialysis via stretcher to assigned room. The client was alert, oriented x 4. Denied any pain. He stated he felt ‘tired and dizzy.’ The client reported that the dizziness occurred when he quickly changed positions. The client was assessed, and vital signs were obtained.
Vital Signs
• Temperature 97° F (36° C)
• Pulse 94/minute; irregular
• Respirations 14/minute
• Blood Pressure 91/58 mm Hg
• Oxygen saturation 92% on room air
Assessment
Neurological:
Alert and completely oriented; reports dizziness. Pupils, equal, round, and reactive to light.
Cardiovascular:
Peripheral pulses intact; no edema; S1/S2 heart tones. Positive bruit and thrill in left arm A/V fistula. Gauze dressing applied which is dry with a scant amount of dry blood
Respiratory:
Diminished lung sounds, occasional cough
GI/GU:
Normoactive bowel sounds in all quadrants. Anuria.
Skin:
Warm and dry
Medical History
• End-stage renal disease (ESRD)
• Uncontrolled hypertension
• Chronic obstructive pulmonary disease
• Atrial fibrillation
The nurse reviews the nursing note, vital signs, assessment, and medical history. Which clinical data is most concerning to the nurse? Select all that apply.
Rationale:
C: Pulse indicates an irregular rhythm, which is particularly alarming in a patient with atrial fibrillation. This can lead to serious complications such as stroke or heart failure if not monitored closely.
D: Blood pressure at 91/58 mm Hg is concerning as it reflects hypotension, especially in a client with uncontrolled hypertension. This low reading can lead to inadequate perfusion and potential organ failure.
E: Neurological assessment showing dizziness is significant, particularly given the client’s history of atrial fibrillation. Dizziness can indicate inadequate cerebral perfusion or other neurological issues requiring immediate attention.
G: Anuria is critical as it signifies a lack of urine output, suggesting severe kidney impairment or failure. This is particularly alarming given the patient’s end-stage renal disease.
A: A/V fistula assessment is important; however, the positive bruit and thrill are expected findings. The dressing being dry indicates no immediate complications, making it less concerning in this context.
B: Oxygen saturation at 92% on room air is slightly low but not critically alarming for a patient with chronic obstructive pulmonary disease. It does not indicate immediate life-threatening issues.
F: Temperature at 97°F is within normal limits, presenting no immediate concern. Stable temperatures do not indicate any ongoing infection or acute illness in this scenario, minimizing its urgency.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 6 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 transfers the client to the intensive care unit for further management. Eight hours later, the nurse in the ICU reassesses the client and determines which findings indicate that the treatment is effective. Select all that apply.
Rationale:
Serum sodium 132 mEq/L, Glasgow Coma Scale score of 15, orientation to person, situation, place, and time, and decreased lower extremity weakness indicate that the treatment is effective.
Effective treatment is suggested by a serum sodium level of 132 mEq/L, reflecting improvement from severe hyponatremia. Additionally, a GCS score of 15 and full orientation demonstrate cognitive recovery, while decreased weakness indicates enhanced physical stability.
A: Pulse 105 Excessively elevated heart rate may indicate ongoing distress or fluid imbalance, suggesting that the client has not yet stabilized despite treatment efforts.
B: Serum sodium 132 mEq/L This option is correct as it shows improvement in sodium levels, indicating effective treatment for hypernatremia.
C: Glasgow Coma Scale (GCS) score of 15 An optimal GCS score denotes full consciousness, reflecting positive neurological recovery and effective management of the client's condition.
D: Orientation to person, situation, place, and time This finding confirms cognitive recovery, indicating that the treatment has positively impacted the client’s mental status and overall condition.
E: Decreased lower extremity weakness Improvement in lower extremity strength shows progress in physical health, indicating that the treatment has had a beneficial effect on the client’s overall condition.
The nurse is reviewing the client's laboratory data. Which current prescription should the nurse clarify with the primary healthcare provider (PHCP)?
Rationale:
Dextrose 5% in water (D5W) should be clarified with the primary healthcare provider. This solution can lead to fluid overload or inappropriate glycemic control, especially if the client has specific contraindications or conditions requiring careful management of glucose levels.
B: dexamethasone This medication is typically used for inflammatory conditions and does not necessitate clarification based on standard laboratory data interpretations.
C: digoxin This heart medication is often monitored closely, but no specific data indicates a need for clarification in the context provided.
D: ergocalciferol This vitamin D supplement is generally safe and not typically associated with immediate concerns that would warrant clarification in laboratory reviews.
The nurse is reviewing the assignment for the shift and will be caring for the following clients. Which client is at risk for hypokalemia? A client with
Rationale:
A client with hyperemesis gravidarum is at risk for hypokalemia. This condition often leads to excessive vomiting, resulting in significant potassium loss, which can cause electrolyte imbalances and subsequent hypokalemia in affected clients.
B: End-stage renal failure typically results in hyperkalemia due to decreased potassium excretion, making this condition unlikely to lead to hypokalemia.
C: Diabetic ketoacidosis often causes hyperkalemia due to shift of potassium from cells into the bloodstream, not hypokalemia.
D: Third-degree burns can lead to fluid loss and electrolyte imbalances, but they are more commonly associated with hyperkalemia rather than hypokalemia.
A nurse on a medical-surgical unit cares for a client who has just undergone a procedure for a Kock pouch as a treatment for bladder cancer. The initial nursing interventions for this client would include:
Rationale:
Monitoring urine output, checking for indications of ostomy pouch leaks, and noting the size, shape, and color of the stoma are crucial initial nursing interventions for a client with a Kock pouch.
This option is correct as it prioritizes the assessment of the stoma and pouch, which is vital for identifying complications and ensuring the client's immediate wellbeing post-procedure.
B: Speaking to the client's family and updating them regarding the client's status does not address the immediate clinical needs of the client, which are essential for safe recovery.
C: Educating the client about stoma care and skincare is important but not the initial intervention; immediate monitoring of the stoma is crucial for detecting complications first.
D: Irrigating the catheters as needed may be part of later care but does not pertain to the initial assessment and monitoring that must be prioritized after surgery.
The nurse is reviewing the concept of acute kidney injury (AKI) with a student nurse. Which of the following would be correct as a cause of prerenal AKI?
Rationale:
Hypovolemia is a primary cause of prerenal AKI as it leads to decreased blood flow to the kidneys, resulting in impaired glomerular filtration and subsequent kidney function decline.
A: nephrotoxicity Excessive exposure to nephrotoxic agents primarily affects kidney tissues directly, which correlates with intrinsic renal injury rather than prerenal causes.
B: bladder cancer This condition relates to obstructive uropathy or intrinsic kidney damage; it does not contribute to prerenal AKI, which is associated with blood flow issues.
C: contrast media While contrast-induced nephropathy can lead to AKI, it is categorized under intrinsic renal injury rather than the prerenal type, focusing on direct kidney damage.
The following scenario applies to the next 1 items
The student nurse is assisting the nurse in caring for a 31-year-old female in the outpatient clinic.
Item 1 of 1
Nurses' Note
1415: The client requested her annual physical be moved up because of urinary symptoms that started nine months ago. She states that she has managed so far with them, but she is starting a new traveling job and would like to get any necessary treatment. She states that every time she laughs or sneezes, she leaks a small amount of urine. She reports that this also occurs while performing intense physical exercise. The symptoms occur daily. She denies increased frequency, urgency, and burning upon urination. She denies having any vaginal discharge. She was treated for a urinary tract infection two months ago with antibiotics.
Diagnostic Results
1500:
Bladder scan - post-void residual
20 mL
Medical History
• Chronic low back pain following a motor vehicle crash
• Obstetric history - G = 2, T = 2 (vaginal deliveries), P = 0, A = 0, L = 2
The nurse reviews the concept of urinary incontinence, its causes, and symptoms with the student nurse. Click to specify if the causes or symptoms are consistent with the disease process of stress incontinence, overflow incontinence, or urge incontinence.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Urine loss with physical exertion, cough, sneeze, or exercise
B
Palpable bladder during assessment
C
Caused by neurologic disorders, such as multiple sclerosis or spinal cord damage
D
Caused by vaginal prolapse from vaginal birth or aging
E
Caused by bladder irritants, such as artificial sweeteners, caffeine, alcohol
F
Caused by constipation
G
Loss of large amounts of urine with each occurrence
Rationale:
Urine loss with physical exertion, cough, sneeze, or exercise. This description aligns with stress incontinence, characterized by involuntary leakage during activities that increase abdominal pressure, such as laughing or exercising, as reported by the patient.
B: Palpable bladder during assessment indicates overflow incontinence, characterized by retention and inability to empty the bladder fully, not related to stress-induced leakage.
C: Caused by neurologic disorders, such as multiple sclerosis or spinal cord damage, relates to urge incontinence, where nerve dysfunction leads to sudden urges, differing from stress incontinence.
D: Caused by vaginal prolapse from vaginal birth or aging describes a potential risk factor but does not directly define the leakage symptoms associated with stress incontinence.
E: Caused by bladder irritants, such as artificial sweeteners, caffeine, alcohol, pertains to urge incontinence, where irritants trigger sudden urges, which diverges from stress-related urinary loss.
F: Caused by constipation refers to overflow incontinence, which results from fecal impaction leading to urinary retention and does not connect to stress incontinence symptoms.
G: Loss of large amounts of urine with each occurrence characterizes overflow incontinence, which involves involuntary leakage due to excessive bladder fullness rather than stress-related incidents.
The nurse reviews a client's laboratory results and notes the potassium level is 5.6 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. Which change to the cardiac rhythm would be expected?
Rationale:
Tall, peaked T waves. Elevated potassium levels, such as 5.6 mEq/L, can lead to characteristic changes in cardiac rhythm, notably the appearance of tall, peaked T waves on an ECG due to altered cardiac repolarization processes.
B: ST segment elevation. ST segment elevation is typically associated with conditions like myocardial ischemia rather than hyperkalemia, which specifically influences T wave morphology instead of the ST segment.
C: Peaked P waves. Peaked P waves are indicative of right atrial enlargement and not related to hyperkalemia, which primarily alters T wave presentation rather than affecting P wave characteristics.
D: Noticeable U waves. U waves are often associated with hypokalemia or certain medications, not hyperkalemia. Elevated potassium levels lead to T wave changes instead of promoting U wave visibility.
The nurse is caring for a client with hyperkalemia. Which of the following treatments would the nurse recognize as appropriate options for treating this electrolyte imbalance? Select all that apply.
Rationale:
B: Sodium polystyrene, C: Regular insulin, and D: Hemodialysis are appropriate treatments for hyperkalemia. These interventions effectively lower potassium levels through ion exchange, cellular shifting, and removal via dialysis, respectively.
A: Spironolactone antagonizes aldosterone, potentially increasing potassium levels, which is counterproductive for hyperkalemia management.
E: Magnesium sulfate does not address potassium excess directly and may exacerbate hyperkalemia in certain clinical scenarios, thus not suitable for immediate treatment.
A newly hired nurse is caring for a client who is receiving prescribed total parenteral nutrition (TPN) therapy. The nurse preceptor should intervene if the newly hired nurse?
Rationale:
C: Spikes and primes a new bag of TPN without an inline filter. This action poses a risk of introducing particulate matter or microorganisms, which can lead to serious complications such as infection or embolism during TPN administration, thus requiring immediate intervention from the preceptor.
A: Wears a surgical mask while changing the client's central vascular access dressing. Using a surgical mask is appropriate for maintaining a sterile environment, helping to prevent contamination during the dressing change.
B: Obtains the client's capillary blood glucose every four to six hours. Regular monitoring of blood glucose levels is essential for clients on TPN to ensure proper metabolic management and adjust therapy as needed.
D: Continues the infusion via an infusion pump while the client is receiving a computed tomography scan. Maintaining the infusion during imaging procedures is often necessary for patient care, and protocols typically allow this under specific circumstances and monitoring.
The nurse understands that which of the following are complications of acute tubular necrosis (ATN)? Select all that apply.
Rationale:
Acute tubular necrosis (ATN) can lead to metabolic acidosis, hyponatremia, and electrolyte imbalances. These complications arise from the kidney's impaired ability to regulate acid-base balance and electrolyte levels, crucial for homeostasis.
B: High thyroxine levels. Thyroxine levels are typically not directly affected by ATN, as this condition primarily impacts renal function rather than thyroid hormone regulation.
D: Decreased parathyroid levels. Parathyroid hormone levels usually remain stable or increase in response to electrolyte imbalances in renal dysfunction, rather than decreasing as a direct result of ATN.
The following scenario applies to the next 6 items.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 3 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.
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.
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)]
The client is demonstrating manifestations consistent with......... due to.......
Rationale:
The client is demonstrating manifestations consistent with syndrome of inappropriate antidiuretic hormone due to small cell lung cancer.
The client exhibits hyponatremia with a sodium level of 116 mEq/L, indicative of inappropriate fluid retention. His disorientation and lower extremity weakness further support this condition, often associated with small cell lung cancer due to ectopic hormone production. The rapid onset of symptoms corroborates this diagnosis.
A: Cushing's syndrome Severe hypernatremia typically characterizes Cushing's syndrome, which this client does not exhibit. The low sodium level contradicts this diagnosis, making it an unlikely consideration.
B: diabetes insipidus Symptoms include polyuria and polydipsia, which are absent in this scenario. The client's low sodium and confusion are more aligned with fluid overload rather than excess fluid loss.
D: advanced chronic obstructive pulmonary disease While the client has a history of COPD, the acute disorientation and electrolyte imbalance are not typical manifestations of this chronic disease, thereby ruling it out.
F: corticosteroid usage Although corticosteroids can influence fluid balance, the specific symptoms of disorientation and hyponatremia are more accurately linked to the cancer itself rather than solely steroid effects.
Following surgery for a prolapsed bladder, a 74-year-old female client is two days postoperative with an indwelling urinary catheter. While the nurse is making morning rounds, the client states, 'I feel like peeing again!' The most appropriate response for the nurse is:
Rationale:
B: Let me look at your urine bag to ensure it's draining properly. This response addresses the client's immediate concern by verifying the catheter's function, which is crucial for postoperative care and preventing complications.
A: It's just bladder spasms. Nothing to worry about. This minimizes the client's concern without assessing the situation, potentially overlooking an important issue related to catheter drainage or bladder function.
C: You should do Kegel exercises regularly to stop this urge to void. Suggesting Kegel exercises may not be appropriate immediately post-surgery, as the client’s focus should be on healing and monitoring urinary output.
D: Is this the first time this has happened? While gathering history is important, this response does not provide immediate reassurance or address the current situation regarding the indwelling catheter.
The nurse reviews the lab values of a client and notes a serum sodium level of 125 mEq/L (mmol/L) [Reference range: 135-145 mEq/L (mmol/L)]. Which conditions does the nurse recognize as potential causes of this laboratory abnormality? Select all that apply.
Rationale:
Serum sodium levels of 125 mEq/L indicate hyponatremia, which can result from conditions such as syndrome of inappropriate antidiuretic hormone (SIADH), Addison's disease, and psychogenic polydipsia.
A: syndrome of inappropriate antidiuretic hormone (SIADH) SIADH causes excessive water retention due to increased ADH levels, diluting serum sodium and leading to hyponatremia.
B: diabetes Insipidus Diabetes Insipidus results in excessive urination and potential hypernatremia, not hyponatremia, as water loss concentrates serum sodium levels instead of diluting them.
C: addison's disease (adrenal insufficiency) Addison's disease typically results in low cortisol levels, leading to electrolyte imbalances, but it primarily causes hyperkalemia rather than directly influencing serum sodium levels to cause hyponatremia.
D: psychogenic polydipsia Excessive water intake from psychogenic polydipsia can dilute serum sodium, resulting in hyponatremia due to an overload of fluid rather than a lack of sodium itself.
E: salt water drowning Salt water drowning introduces a high sodium concentration, potentially leading to hypernatremia, contrasting with the hyponatremia indicated by the client’s serum sodium level.
As a nurse, you are administering intravenous fluids to a client. Which of the following types of IV fluids would be classified as isotonic? Select all that apply.
Rationale:
Normal saline and Lactated ringers are isotonic IV fluids. They maintain osmotic balance and are commonly used to replace fluids and electrolytes without altering the client's cellular environment significantly.
B: 1/2 Normal saline This solution is hypotonic, which means it lowers osmolarity, potentially causing cellular swelling and is not suitable for maintaining isotonicity in IV therapy.
D: D10W This fluid is hypertonic due to its high dextrose concentration, which can lead to cellular dehydration rather than maintaining osmotic stability.
E: 3% NaCl This solution is also hypertonic, significantly raising osmolarity and drawing water out of cells, which is contrary to the purpose of isotonic fluids.
The nurse is reviewing the laboratory results of a client with renal failure. Which laboratory data requires immediate follow-up?
Rationale:
Serum potassium 6 mEq/L (mmol/L) [3.5-5.0 mEq/L] requires immediate follow-up. Elevated potassium levels can lead to dangerous cardiac complications, making it a critical lab value in patients with renal failure who are at risk for hyperkalemia.
A: Blood urea nitrogen 50 mg/dL [10-20 mg/dL] While elevated, this value is not immediately life-threatening and can be managed with appropriate interventions over time in renal failure patients.
C: Arterial blood pH 7.30 [7.35-7.45] This slightly acidic pH indicates mild acidosis, which is concerning but often manageable without the same urgency as hyperkalemia in renal failure.
D: Hemoglobin 10.3 g/dL (1.03 g/L) [F: 12-16 g/dL (7.4 -9.9 mmol/L) M: 14-18 g/dL (8,7-11.2 mmol/L)] Low hemoglobin can indicate anemia, but it typically does not require immediate intervention compared to the urgent need for addressing hyperkalemia.
Intravenous therapies often consist of electrolyte replacement therapies. Select the electrolyte that is accurately paired with one of its functions.
Rationale:
Sodium: The control and management of circulating blood volume.
Sodium plays a critical role in maintaining fluid balance and regulating blood volume within the circulatory system. Its importance in homeostasis makes it essential for proper cardiovascular function and overall health, justifying its pairing with this specific function in electrolyte replacement therapies.
B: Bicarbonate: Although bicarbonate is important for acid-base balance, it does not primarily regulate extracellular fluid, which is mainly influenced by sodium levels.
C: Chloride: Chloride aids in maintaining osmotic pressure and fluid balance but does not directly regulate plasma protein levels, which are influenced by other factors.
D: Calcium: While calcium is vital for various metabolic processes, it is not primarily responsible for the metabolism of fats, carbohydrates, and proteins; this function is mainly attributed to other nutrients.
The nurse cares for a client with a serum sodium level of 152 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which of the following assessment findings would be expected? Select all that apply.
Rationale:
Elevated serum sodium levels indicate hypernatremia, leading to symptoms such as lethargy, dry mucous membranes, and excessive thirst. These findings are indicative of dehydration and cellular fluid shifts due to high sodium concentration.
A: Lethargy A common symptom of hypernatremia, reflecting the central nervous system's response to fluid imbalance and dehydration effects on neuronal function.
B: Dry mucous membranes Indicative of dehydration, which results from the body's attempt to balance high sodium levels, causing reduced moisture in mucosal tissues.
C: Tachypnea Increased breathing rate is not typically associated with hypernatremia, as it primarily affects fluid balance rather than directly impacting respiratory drive or function.
D: Cyanosis This indicates oxygen deprivation in tissues, which is unrelated to elevated sodium levels and typically signifies respiratory or circulatory issues instead.
The following scenario applies to the next 1 items
The nurse is reviewing the medical record of a 55-year-old male client.
Item 1 of 1
History and Physical
0818: Client reports severe shortness of breath and swelling in his lower extremities. He reports a 3-day history of fatigue and decreased urine output. During the assessment, the client was alert and fully oriented. He has 2+ pitting pedal edema in the lower extremities. 2+ peripheral pulses in the upper extremities. Bibasilar crackles upon auscultation. Skin is warm, dry, and normal for ethnicity. Normoactive bowel sounds in all quadrants. Vital signs: T 98° F (36.7°C), P 89, RR 18, BP 164/95, pulse oximetry reading 96% on room air.
Laboratory Results
• Capillary blood glucose 121 mg/dL (6.72 mmol/L) [70-110 mg/dL (4-6 mmol/L)]
• Serum creatinine 2.5 mg/dL (221 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Serum BUN 36 mg/dL (12.9 mmol/L) ([10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum potassium: 5.2 mEq/L [3.5–5 mEq/L (3.5–5 mmol/L)]
• Urinalysis: Mild proteinuria, no hematuria
Intake and Output
24 hour fluid intake: 1560 mL
24 hour fluid output: 250 mL
Medical History
• hypertension
• hyperlipidemia
• coronary artery disease
• glaucoma
• diabetes mellitus (type two)
Current Medications
• carvedilol 6.25 mg p.o. daily
• multivitamin 1 tablet p.o. daily
• lisinopril 10 mg p.o. daily
• simvastatin 10 mg p.o. daily
• ergocalciferol 10000 units p.o. daily
• ethyl eicosapentaenoic acid 2 grams p.o. daily
The nurse is reviewing the client's assessment data to prepare the client's care plan. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Prepare the client for peritoneal dialysis, Request a prescription for sodium chloride (normal saline) 500 mL bolus, Obtain an order to discontinue the lisinopril, Obtain a prescription for a continuous infusion of regular insulin, Request a prescription for a diuretic.
B
Nephrotic syndrome, Hyperglycemia hyperosmolar syndrome, Acute kidney injury, Chronic kidney disease.
C
Peripheral pulses, Capillary blood glucose, Serum potassium, Temperature, Lung sounds.
Rationale:
Acute kidney injury. This condition is indicated by the client's elevated serum creatinine and BUN levels, along with decreased urine output, suggesting impaired renal function requiring immediate intervention.
A: Request a prescription for a diuretic. While diuretics may help reduce edema, they do not directly address the underlying acute kidney injury.
C: Nephrotic syndrome. This condition typically presents with significant proteinuria and hypoalbuminemia, which are not evident in the client’s assessment data.
D: Hyperglycemia hyperosmolar syndrome. The client’s blood glucose level is elevated but not critically high, and the symptoms do not align with this syndrome’s presentation.
E: Chronic kidney disease. The client exhibits acute changes rather than the gradual decline seen in chronic kidney disease, making this diagnosis inappropriate.
The nurse is providing discharge instructions to a client prescribed phenazopyridine. Which of the following instructions should the nurse include?
Rationale:
Your urine will turn orange in color. Phenazopyridine is known to cause a noticeable change in urine color, which is a benign side effect indicating the medication's action on urinary pain relief.
A: The amount of urine you void will increase. Phenazopyridine does not affect urine volume; it primarily alleviates discomfort associated with urinary tract conditions rather than altering urinary output.
C: You may notice that your urine is malodorous. This medication does not typically influence the odor of urine, focusing instead on providing symptomatic relief from irritation without altering its scent.
D: Concentrated urine is an expected finding. While concentrated urine may occur for various reasons, phenazopyridine specifically does not contribute to changes in urine concentration, nor is it a direct effect of the medication.
The nurse is assigned to care for a client with a sodium level of 122 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which assessment findings does the nurse anticipate based on this lab result?
Rationale:
Confusion, abdominal cramps, and nausea and vomiting are anticipated assessment findings for a client with a sodium level of 122 mEq/L, indicating hyponatremia that affects neurological and gastrointestinal functions.
C: Tall, peaked t-waves indicate hyperkalemia rather than hyponatremia. This electrolyte imbalance typically presents with different cardiac manifestations, not associated with low sodium levels.
D: Hypoactive bowel sounds are typically linked to other electrolyte imbalances, such as hypercalcemia or hypokalemia. They do not specifically correlate with low sodium levels in this context.
A client with chronic kidney disease (CKD) is receiving hemodialysis treatment. Which of the following nursing interventions should be implemented for this client? Select all that apply.
Rationale:
Monitor the client's blood pressure before, during, and after hemodialysis; administer erythropoietin (EPO) as prescribed; assess the client's access site for signs of infection or thrombosis; and administer phosphate binders as prescribed.
Monitoring blood pressure is critical to detect hypotension during dialysis, erythropoietin aids in red blood cell production due to anemia in CKD, assessing access sites prevents complications, and phosphate binders manage elevated phosphate levels effectively.
C: Restrict protein intake to minimize uremic symptoms. Protein restriction is not universally recommended during hemodialysis, as adequate protein intake is essential to prevent malnutrition in these patients.
F: Encourage the client to consume a high-potassium diet to prevent electrolyte imbalances. A high-potassium diet can lead to hyperkalemia, which is a significant risk for clients with chronic kidney disease undergoing hemodialysis.
The nurse is assessing a client's electrocardiogram (ECG) monitoring and notices U-waves. Which electrolyte abnormality may cause this finding?
Rationale:
U-waves on an electrocardiogram (ECG) monitoring are indicative of hypokalemia. This electrolyte deficiency can lead to changes in cardiac repolarization, resulting in the appearance of U-waves following the T-wave.
A: Hyperkalemia Excess potassium typically causes peaked T-waves and may lead to arrhythmias, not U-waves, indicating a distinctly different cardiac effect than hypokalemia.
C: Hypernatremia Elevated sodium levels primarily affect fluid balance and do not directly relate to U-wave formation on an ECG, making this option irrelevant to the finding.
D: Hyponatremia Low sodium levels influence fluid balance and may cause confusion or seizures but do not produce U-waves, failing to connect to the observed ECG changes.
The nurse is caring for a client with urge incontinence. Which of the following actions would be appropriate for the nurse to take?
Rationale:
C: Have the client void on a timed schedule. Timed voiding is a beneficial strategy for managing urge incontinence. It helps establish a routine and reduces the frequency of involuntary leaking, promoting better bladder control and enhancing the client’s quality of life.
A: Administer prophylactic antibiotics. This approach does not address urge incontinence directly and may lead to unnecessary antibiotic resistance without solving the underlying issue.
B: Teach the client intermittent self-catheterization. This technique is more suitable for overflow incontinence, rather than urge incontinence, and may not effectively manage the client’s primary symptoms.
D: Provide caffeinated beverages with meals. Caffeine can exacerbate bladder irritability and increase urgency, making it counterproductive for someone experiencing urge incontinence.
Which nursing assessment finding are consistent with hypocalcemia? Select all that apply.
Rationale:
Chvostek's sign, Trousseau's sign, and numbness and tingling of the fingers and toes are consistent findings in hypocalcemia, indicating neuromuscular excitability due to low calcium levels in the body.
B: Grey-Turner's sign indicates retroperitoneal hemorrhage and is unrelated to calcium levels, focusing instead on bleeding and bruising.
C: Homan's sign is used to assess deep vein thrombosis, not calcium-related issues, and has no relevance to hypocalcemia symptoms.
When assessing for dehydration, the nurse should observe for which of the following?
Rationale:
Hypotension, headache, and dry mucous membranes. These signs indicate significant fluid loss and are classic indicators of dehydration, helping the nurse identify a patient's compromised hydration status effectively.
A: Headache and increased urinary output. While headache can signal dehydration, increased urinary output typically suggests adequate hydration, contradicting the assessment of dehydration.
B: Weight gain and edema. These symptoms typically indicate fluid retention, not dehydration, as excess fluid leads to swelling rather than a deficit of bodily hydration.
C: Hypertension and decreased urinary output. Hypertension is not a typical sign of dehydration; rather, decreased urinary output suggests fluid retention, which does not align with dehydration assessment.
The nurse cares for a client with a potassium of 5.7 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The nurse understands that this potassium level may be caused by Select all that apply.
Rationale:
C: Salt substitutes contain high levels of potassium, which can significantly elevate serum potassium levels. This dietary source can contribute to hyperkalemia, especially in individuals with existing kidney issues or those consuming large amounts.
E: Adrenal insufficiency leads to decreased aldosterone production, impairing potassium excretion by the kidneys. This can result in elevated potassium levels, making it a relevant cause of hyperkalemia.
A: Cushing's disease typically leads to high cortisol levels, which promote potassium excretion, thus lowering potassium levels rather than elevating them.
B: Nasogastric tube suctioning generally removes gastric contents, which may lead to electrolyte imbalances but does not typically raise potassium levels.
D: Hyperinsulinism usually drives potassium into cells, causing lower serum potassium levels rather than an increase, making it an unlikely cause of elevated potassium.
The nurse is caring for a client who has fluid volume deficit receiving intravenous fluids. Which of the following would indicate the client is achieving the treatment goals?
Rationale:
BUN 15 mg/dL (5.355 mmol/L) indicates the client is achieving treatment goals. This level falls within the normal range, reflecting adequate kidney function and hydration status, suggesting effective fluid resuscitation and stabilization of fluid volume.
A: urine output 20 mL/hr This low urine output suggests inadequate renal perfusion and insufficient fluid volume status, indicating that treatment goals have not been met effectively.
C: urine specific gravity 1.039 A high specific gravity indicates concentrated urine, which signifies dehydration rather than achievement of fluid volume goals, showing the client still requires more fluids for proper hydration.
D: flattened jugular veins Flattened jugular veins suggest decreased venous return and potential hypovolemia, indicating that fluid volume deficit persists and that the treatment goals have not been satisfactorily reached.