Adult II Exam #4 – Flashcards
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A patient has an AV fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which of the following measures should the nurse implement to promote client safety? a. Take blood pressures only in the right arm to ensure safety. b. Use the fistula for all venipunctures and intravenous infusions c. Ensure that small clamps are attached to the AV fistula dressing. d. Assess the fistula for the presence of a bruit and thrill every 4 hours
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d. AV fistulas are created by an anastamosis of an artery and a vein within the subcutaneous tissues to create access for hemodialysis. Fistulas should be evaluated for the presence of thrills (palpate over the area) and bruits (auscultate with a stethoscope) as an assessment of patency. Blood pressures or venipunctures are not done on the extremity with the fistula because of the clotting, infection, or damage to the fistula.
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The home care nurse is making follow-up visits to a client after renal transplant. The nurse assesses the client for which signs of acute graft rejection? a. Hypotension, graft tenderness, anemia b. Hypertension, oliguria, thirst, and hypothermia c. Fever, hypertension, graft tenderness, and malaise d. Fever, vomiting, hypotension, and copious amounts of dilute urine output
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c. Acute rejection usually occurs within the first 3 months after transplant, although it can occur for up to 2 years post transplant. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment is immediately begun with corticosteroids and possibly also with monoclonal antibodies and anti lymphocyte agents.
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A client is scheduled for computed tomography (CT) of the kidneys to rule out renal disease. As an essential preprocedure component of the nursing assessment, the nurse plans to ask the client about a history of: a. Allergies b. Familial renal disease c. Frequent antibiotic use d. Long-tern diuretic therapy
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a. The client undergoing any type of diagnostic testing involving possible dye administration should be questioned about allergies, specifically an allergy to shellfish or iodine. This is essential to identify the risk for potential allergic reaction to contrast dye, which may be used. The other items are also useful as part of the assessment but are not as critical as the allergy determination in the preprocedure period.
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The nurse assists a client who has a renal disorder collect a 24-hour urine specimen. Which does the nurse implement to ensure proper collection of the 24-hour specimen? a. Have the client void at the start time and discard the specimen. b. Strain the specimen before pouring the urine into the container. c. Save all urine, beginning with the urine voided at the start time. d. Once completed, refrigerate the urine collection until picked up by the laboratory.
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a. The nurse asks the client to void at the beginning of the collection period and discards this urine sample because the urine has been stored in the bladder for an undetermined length of time. All urine thereafter is saved in an iced or refrigerated container. The client is asked to void at the finish time, and this sample is the last specimen added to the collection. Straining the urine is contraindicated for timed urine collections. The container is labeled, placed on fresh ice, and send to the laboratory immediately.
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The nurse plans care for a client diagnosed with end stage renal disease (ESRD). Which findings does the nurse expect to find in the client's medical record? Select all that apply. a. edema b. anemia c. polyuria d. bradycardia e. hypotension f. osteoporosis
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a & b The manifestations of ESRD are the result of impaired kidney function. Two functions of the kidney are maintenance of water balance in the body and the secretion of erythropoietin, which stimulates red blood cell formation in bone marrow. Impairment of these functions results in edema and anemia. Kidney failure results in decreased urine production and increased blood pressure. Tachycardia is a result of increased fluid load on the heart. Osteoporosis is not a common finding with ESRD.
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A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history taking the nurse should first ask the client about a recent history of: a. Bleeding ulcer b. DVT c. Myocardial Infarction d. Streptococcal infection
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d. The predominant cause of acute glomerulonephritis is infection with beta hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infections agents that could trigger the disorder include viruses, fungi, and parasites. Bleeding ulcer, DVT, and MI are not precipitating causes.
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A nurse is assigned to care for a client with nephrotic syndrome. The nurse assesses which important parameter on a daily basis? a. Weight b. Albumin levels c. Activity tolerance d. BUN level
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a. The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake, and output, edema, and girth measurements. Albumin levels are monitored as they are prescribed, as are the BUN and creatinine levels. The client's activity level is adjusted according to the amount of edema and water retention. As edema increases, the client's activity level should be restricted.
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A client is being admitted to the hospital with a diagnosis of urolithiasis and ureteral colic. The nurse assesses the client for pain that is: a. Dull and aching in the costovertebral area b. Aching and cramplike throughout the abdomen c. Sharp and radiating posteriorly to the spinal column d. Excruciating, wavelike, and radiating toward the genitalia
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d. The pain of ureteral colic is caused by movement of a stone through the ureter and is sharp, excruciating, and wavelike, radiating to the genitalia and thigh. The stone causes reduced flow of urine, and the urine also contains blood because of its abrasive action on urinary tract mucosa. Stones in the renal pelvis cause pain that is a dull ache in the costovertebral area. Renal colic is characterized by pain that is acute with tenderness over the costovertebral area.
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A client with renal failure is receiving epoetin alfa (Epogen) to support erythropoiesis. The nurse questions the client about compliance with taking which of the following medications that supports RBS production? a. Iron supplement b. Zinc supplement c. Calcium supplement d. Magnesium supplement
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a. Iron is needed for RBC production; otherwise, the body cannot produce sufficient erythrocytes. In either case the client is not receiving the full benefit of epoetin alfa therapy if iron is not taken.
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The nurse is caring for a client scheduled to undergo renal biopsy. To minimize the risk of postprocedure complications, the nurse reports which of the following laboratory results to the physician before the procedure? a. Potassium: 3.8 mEq/L b. Serum creatinine: 1.2 mg/dL c. Prothrombin time: 15 seconds d. Blood urea nitrogen (BUN): 18 mg/dL
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c. Postprocedure hemorrhage is a complication after renal biopsy. Because of this, prothrombin time is assessed before the procedure. The normal prothrombin time range is 11 to 12.5 seconds. The nurse ensures that these results are available and reports abnormalities promptly. [Normal BUN is 5 to 20, normal serum creatinine is 0.6 to 1.3, and normal potassium is 3.5 to 5.1. (according to Saunders)]
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A client with acute pyelonephritis has nausea and is vomiting and is scheduled for an intravenous pyelogram. The nurse places highest priority on which action? a. Ask the client to sign the informed consent. b. Explain the procedure thoroughly to the client. c. Place the client on hourly intake and output measurements. d. Request a prescription for an intravenous infusion from the physician.
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d. The highest priority of the nurse would be to request a prescription for an intravenous infusion. This is needed to replace fluid lost with vomiting, will be necessary for dye injection for the procedure, and will assist with the elimination of the dye after the procedure. The intake and output should be measured, but this will not assist in preventing dehydration. Explanation of the procedure and obtaining the signed informed consent are done once the client's physiological needs are met.
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A client with urolithiasis is being evaluated to determine the type of stone that is being formed. The nurse plans to keep which of the following items available in the client's room to assist in this process? a. A strainer b. A calorie count sheet c. A vital signs graphic sheet d. An intake and output record
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a. The urine is strained until the stone is passed, obtained, and analyzed. Straining the urine will catch small stones that may be sent to the laboratory for analysis. Once the type of stone is determined, an individualized plan of care for prevention and treatment is developed.
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A client newly diagnosed with polycystic kidney disease has just finished speaking with the physician about the disorder. The client asks the nurse to explain again what the most serious complication of the disorder might be. In formulating a response, the nurse incorporates the understanding that the most serious complication is: a. Diabetes insipidus b. End-stage renal disease (ESRD) c. Chronic urinary tract infection (UTI) d. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
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b. In polycystic kidney disease, cystic formation and hypertrophy of the kidneys occur. The most serious complication of polycystic kidney disease is ESRD, which is managed with dialysis or transplant. There is no reliable way to predict who will ultimately progress to ESRD. Chronic UTIs are the most common complication because of the altered anatomy of the kidney and from development of resistant strains of bacteria. Diabetes insipidus and SIADH are unrelated disorders.
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A nurse is developing a plan of care for a client who has returned to the nursing unit after left nephrectomy. The nurse should include which assessments in the plan of care? Select all that apply. a. Pain level b. Vital signs c. Hourly urine output d. Tolerance for sips of clear liquids e. Ability to cough and deep breathe
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a, b, c, & e After nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the remaining kidney and detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could affect the client's ability to reposition, cough, and deep breathe. Therefore the next most important measurements are vital signs, pain level, and bed mobility. Clear liquids are not given until the client has bowel sounds.
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The nurse develops a care plan for a client receiving hemodialysis who has an arteriovenous (AV) fistula in the right arm. The nurse includes which interventions in the plan to ensure protecting the AV fistula? Select all that apply. a. Assess pulses and circulation proximal to the fistula b. Palpate for thrills and auscultate for a bruit every 4 hours c. Check for bleeding and infection at hemodialysis needle insertion sites. d. Avoid taking blood pressure or performing venipunctures in the extremity. e. Instruct the client not to carry heavy objects or anything that compresses the extremity. f. Instruct the client not to sleep in a position that places his or her body weight on top of the extremity.
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b, c, d, e, & f An AV fistula is an internal anastomosis of an artery to a vein and is used as an access for hemodialysis. The nurse should implement the following to protect the fistula: avoid taking blood pressures or performing venipunctures in the extremity, palpate for thrills and auscultate for a bruit every 4 hours, assess pulses and circulation distal to the fistula, check for bleeding and infection at hemodialysis needle insertion sites, instruct the client not to carry heavy objects or anything that compresses the extremity, and instruct the client not to sleep in a position that places his or her body weight on top of the extremity.
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A client with calcium oxalate renal calculi is told to limit dietary intake of oxalate. The nurse provides the client with a list of foods high in oxalate and places which items on the list? Select all that apply. a. Beets b. Spinach c. Rhubarb d. Black tea e. Cantaloupe f. Watermelon
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a, b, c, & d Food items that are high in oxalate include spinach, black tea, rhubarb, Swiss chard, cocoa, beets, wheat germ, cashews, almonds, pecans, peanuts, okra, chocolate, and lime peel.
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A nurse is admitting to the nursing unit a client who has an arteriovenous (AV) fistula in the right arm for hemodialysis. The nurse plans to best prevent injury to the site by implementing which of the following? a. Applying an allergy bracelet to the right arm b. Putting a large note about the access site on the from of the medical record c. Telling the client to inform all caregivers who enter the room about the presence of the access site d. Placing a sign at the bedside that says "No blood pressure (BP_ measurements or venipunctures in the right arm"
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d. There should be no venipunctures or blood pressure measurements in the extremity with a hemodialysis access device. This is commonly communicated to al caregivers by placing a sign at the client's bedside. An allergy bracelet is places on the client with an allergy. Placing a note on the front of the medical record does not ensure that everyone caring for the client is aware of the access device. The client should not be responsible for informing the caregivers. Some health care agencies, however, do have policies that require a wrist bracelet of some type to be placed on the client with a hemodialysis access device.
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A client with chronic renal failure has an indwelling peritoneal catheter in the abdomen for peritoneal dialysis. While bathing, the client spills water on the abdominal dressing covering the abdomen. The nurse plans to immediately: a. Change the dressing b. Reinforce the dressing c. Flush the peritoneal dialysis catheter d. Scrub the catheter with povidone-iodine.
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a. Clients with peritoneal dialysis catheters are at high risk for infection. A dressing that is wet is a conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumference. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.
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The nurse is teaching a client with acute renal failure to include proteins in the diet that are considered high-quality or complete proteins. The nurse determines that the client needs further teaching if he indicates that which food item is considered high quality. a. Fish b. Eggs c. Chicken d. Broccoli
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d. High-quality or complete proteins come from animal sources and include such foods as eggs, chicken, meat, and fish. Low-quality or incomplete proteins are derived from plant sources and include vegetables and foods made from grains. Because the renal diet is limited in protein, it is important that the proteins ingested are of high quality.
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The nurse has completed instructions regarding diet and fluid restriction for the client with chronic renal failure. The nurse determines that the client understand the information presented if the client selected which dessert from the dietary menu? a. Jell-O b. Sherbet c. Ice cream d. Angel food cake
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d. Dietary fluid includes anything that is liquid at room temperature. This includes items such as Jell-O, sherbet, and ice cream. For clients on a fluid restricted diet, it is helpful to avoid "hidden" fluids to whatever extent possible. This allows the client to take in more fluid by drinking, which can help alleviate thirst.
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The nurse has given instructions to the client with chronic renal failure about reducing pruritus from uremia. The nurse determines that the client needs further instructions if the client states to use which items for skin care? a. Mild soap b. Oil in the bath water c. Lanolin-based lotion d. Alcohol cleansing pads
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d. The client with chronic renal failure often has dry skin that is accompanied by itching (pruritus) from uremia. Products that contain perfumes or alcohol increase skin dryness and pruritus; these should be avoided. The client should use mild soaps, lotions, and bath oils to reduce dryness without increasing skin irritation.
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A client with chronic renal failure is about to begin hemodialysis therapy. The client asks the nurse about the frequency and scheduling of hemodialysis treatments. The nurse tells the client that the typical schedule is: a. 2 hours of tx 6 days per week b. 5 hours of tx 2 days per week c. 2 to 3 hours of tx 5 days per week d. 3 to 4 hours of tx 3 days per week
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d. The typical schedule for hemodialysis is 3 to 4 hours of treatment 3 days per week. Individual adjustments may be made according to certain variables, such as the size of the client, the type of dialyzer, the rate of blood flow, and personal client preferences.
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The nurse has completed client teaching with a hemodialysis client regarding the self-monitoring of the fluid status between hemodialysis treatments. The nurse determines that the client understands the information given if the client states the need to record which of the following on a daily basis? a. Activity b. Pulse and respiratory rate c. Intake, output, and weight d. BUN and creatinine levels
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c. The client receiving hemodialysis should monitor his or her fluid status between hemodialysis treatments. This can be done by recording intake and output and measuring weight on a daily basis. Ideally the hemodialysis client should not gain more than 0.5 kg or weight per day.
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A client who has been diagnosed with chronic renal failure has been told that hemodialysis will be required. The client becomes angry and states, "I'll never ne the same now." The nurse formulates which nursing diagnosis for the client? a. anxiety b. noncompliance c. disturbed body image d. disturbed thought process
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c. A client with a renal disorder such as renal failure may become angry in response to the permanence of the condition. Because of the physical changes and the change in lifestyle that may be required to manage a severe renal condition, the client may experience Disturbed Body Image. Anxiety is not appropriate because the client is able to identify the cause of concern. The client is not stating a refusal to undergo therapy (b) and is nor cognitively impaired (d).
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A 22-year-old female client has recently been diagnosed with polycystic kidney disease. The nurse has a series of discussions with the client that are intended to help the client adjust to the disorder. The nurse plans to include which item as part of one of these discussions? a. Ongoing fluid restriction b. The need for genetic counseling c. The risk of hypotensive episodes d. Depression regarding massive edema
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b. Adult polycystic kidney disease is a hereditary disorder that is inherited as an autosomal-dominant trait. Because of this, the client and his or her extended family should have genetic counseling. Ongoing fluid restriction is unnecessary. The client is likely to have hypertension rather than hypotension. Massive edema is not part of the clinical picture of this disorder.
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A client with nephrotic syndrome asks the nurse, "Why should I even bother trying to control my diet and the edema? It doesn't really matter what I do if I can never get rid of this kidney problem, anyway!" The nurse selects which of the following as the most appropriate nursing diagnosis for this client? a. Anxiety b. Powerlessness c. Ineffective coping d. Disturbed body image
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b. Powerlessness is present when the client believes that personal actions will not affect an outcome in any significant way. Because nephrotic syndrome is progressive, the client may feel that personal actions may not affect the disease process. Anxiety is diagnosed when the client has a feeling of unease with a vague or undefined source. Ineffective coping occurs when the client has impaired adaptive abilities or behaviors with regard to meeting expected demands or roles. Disturbed body image occurs when there is an alteration in the way that the client perceives his or her body image.
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A client with acute renal failure is having trouble remembering information and instructions as a result of altered laboratory values. The nurse avoids doing which of the following when communicating with this client? a. Giving simple, clear directions b. Including the family in discussions related to care c. Explaining treatments using understandable language d. Giving thorough and complete explanations of treatment options
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d. The client with acute renal failure may have difficulty remembering information and instructions because of anxiety and altered laboratory values. Communications should be clear, simply, and understandable. The family is included whenever possible. Information about treatment should be explained using understandable language.
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The nurse has given instructions about site care to a hemodialysis client who has an implantation of an arteriovenous (AV) fistula in the right arm. The nurse determines that the client needs further instructions if the client states the need to: a. Sleep on the right side b. Avoid carrying heavy objects with the right arm c. Perform range-of-motion exercises routinely on the right arm d. Report an increased temperature, redness, or rainage at the site
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a. Routine instructions to the client with an AV fistula, graft, or shunt include reporting signs and symptoms of infection, performing routine range-o-motion exercises of the affected extremity, avoiding sleeping with the body weight on the extremity with the access site, and avoiding carrying heavy objects or compressing the extremity that has the access site.
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The nurse is evaluating the effects of care for the client with nephrotic syndrome. The nurse determines that the client showed the least amount of improvement if which of the following information was obtained serially over 2 days of care? a. Serum albumin 1.9 g/dL, up to 2.0 g/dL b. Initial weight 208 pounds, down to 203 pounds c. Blood pressure 160/90 mmHg, down to 130/78 mmHg d. Daily intake and output record of 2100mL intake and 1900mL output and 2000mL intake and 2900mL output
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a. The goal of therapy in nephrotic syndrome is to heal the leakng glomerular membrane. This would then control edema by stopping the loss of protein in the urine. Fluid balance and albumin levels are monitored to determine the effectiveness of therapy. Option (b) represents a loff of fluid that slightly exceeds 2L and represents a significant improvement. Option (c) shows improvement because both systolic and diastolic blood pressures are lower. Option (d) represents an increased fluid loss. The least amount of improvement is in the serum albumin level because the normal albumin level is 3.5 to 5.0 g/dL.
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A client is being discharged to home while recovering from acute renal failure (ARF). The client indicates an understanding of the therapeutic dietary regimen if the client states the need to eat foods that are lower in: a. Fats b. Vitamins c. Potassium d. Carbohydrates
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c. Most of the excretion of potassium and the control of potassium balance are normal functions of the kidneys. In the client with renal failure, potassium intake must be restricted as much as possible (30 to 50 mEq/day). The primary mechanism of potassium removal during ARF is dialysis.
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A nurse is monitoring a client with chronic kidney disease. Which assessment finding should the nurse report to the healthcare provider? a. Pallor b. Fatigue c. Lethargy d. Petechiae
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d. Chronic kidney disease can cause damage to many body systems. Hematological manifestations that can occur with this disease include anemia and bleeding. Abnormal bleeding (petechiae; purpura; bruising; bleeding from the mucous membranes, nose, or gums; vaginal bleeding; or intestinal bleeding) should be reported to the healthcare provider because it can be life-threatening. Pallor, fatigue, and lethargy are clinical manifestations associated with anemia.
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A client with chronic renal failure has a protein restriction in the diet. The nurse should include in a teaching plan to avoid which of the following sources of incomplete protein in the diet? a. Fish b. Eggs c. Milk d. Nuts
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d. The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are complete proteins with the highest biological value. Foods such as meat, fish, milk, and eggs are complete proteins, which are optimal for the client with chronic renal failure.
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A client with acute renal failure has elevated blood urea nitrogen (BUN). The client is experiencing difficulty remembering information because of uremia. The nurse should use which interventions when communicating with this client? Select all that apply. a. Giving simple, clear directions b. Including the family in discussions related to care c. Giving thorough, lengthy explanations of procedures d. Explaining treatments using understandable language e. Using as many teaching methods available to provide discharge instructions
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a, b, & d The client with acute renal failure may have difficulty remembering information and instructions because of anxiety and the increased level of the BUN. The nurse should avoid giving lengthy explanations about procedures because this information may not be remembered by the client and could increase client anxiety. Communications should be clear, simple, and understandable. The family should be included whenever possible. Using several methods for teaching can be overwhelming for the client. The nurse should assess the client's learning needs and select a method that will facilitate learning.
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You are the admitting nurse for a patient with nephrotic syndrome. Which assessment finding supports this diagnosis? a. Edema formation b. Hypotension c. Increased urine output d. Flank pain
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a The underlying pathophysiology of nephrotic syndrome involves increased glomerular permeability, which allows larger molecules to pass through the membrane into the urine and be removed from the blood. This process causes massive loss of protein, edema formation, and decreased serum albumin levels. Key features include HTN and renal insufficiency (decreased urine output) related to concurrent renal vein thrombosis, which may be a cause or an effect of nephrotic syndrome. Flank pain is seen in patient with acute pyelonephritis.
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You are providing nursing care for a patient with acute kidney failure for whom a nursing diagnosis of Excess Fluid Volume related to compromised regulatory mechanisms has been identified. Which actions should you delegate to an experienced UAP? (Select all that apply.) a. Measuring and recording vital sign values every 4 hours b. Weighing the patient every morning using a standing scale c. Administering furosemide (Lasix) 40 mg orally twice a day d. Reminding the patient to save all urine for intake and output measurement e. Assessing breath sounds every 4 hours f. Ensuring that the patient's urinal is within reach
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a, b, d, f Administering oral medications is appropriate to the scope of practice for an LPN/LVN or RN. Assessing breath sounds requires additional education and skill development and is most appropriately within the scope of practice of an RN, but it may be part of the observations of an experienced an competent LPN/LVN. All other actions are within the educational preparation and scope of practice of an experienced UAP.
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A UAP reports to you that a patient with acute kidney failure has had a urine output of 350 mL over the past 24 hours after receiving furosemide 40 mg IV push. The UAP asks you how this can happen. What is your best response? a. "During the oliguric phase of acute kidney failure, patients often do not respond well to either fluid challenges or diuretics." b. "There must be some sort of error. Someone must have failed to record the urine output." c. "A patient with acute kidney failure retains sodium and water, which counteracts the action of the furosemide." d. "The gradual accumulation of nitrogenous waste products results in the retention of water and sodium."
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a During the oliguric phase of ACF, a patient's urine output is greatly reduced. Fluid boluses and diuretics do not work well. This phase usually lasts from 8 to 15 days. Although there are frequent omissions in recording intake and output, this is probably not the cause of the patient's decreased urine output. Retention of sodium and water is the rationale for giving furosemide, not the reason that it is ineffective. Nitrogenous wastes build up as a result of the kidney's inability to perform their elimination function.
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Your patient is receiving IV piggyback doses of gentamycin (Garamycin) every 12 hours. Which would be your priority for monitoring during the period that the patient is receiving this drug? (22) a. Serum creatinine and BUN levels b. Patient weight every morning c. Intake and output every shift d. Temperature
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a Gentamicin can be a highly nephrotoxic substance. You would monitor creatinine and blood urea nitrogen levels for elevations indicating possible nephrotoxicity. All of the other measures are important but are not specific to gentamicin therapy.
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A patient in whom acute kidney failure has been diagnosed has had a urine output of 1560 mL for the past 8 hours. The LPN/LVN who is caring for this patient, under your supervision, asks you how a patient with kidney failure can have such a large urine output. What is your best response? a. "The patient's kidney failure was due to hypocolemia and we have given him IV fluids to correct the problem." b. "Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may put out as much as 10 L of urine per day." c. "With that much urine output, there must have been a mistake in the patient's diagnosis." d. "An increase in urine output like this is an indicator that the patient is entering the recovery phase of acute kidney failure."
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b Patients with acute kidney failure usually go through a diuretic phase 2 to 6 weeks after the onset of the oliguric phase. The diuresis can result in an output of up to 10 L/day of dilute urine. During this phase it is important to monitor for electrolyte and fluid imbalances. This is followed by the recovery phase. A patient with acute kidney failure caused by hypovolemia would receive IV fluids to correct the problem; however, this would not necessarily lead to the onset of diuresis.
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A patient on the medical-surgical unit with acute kidney failure is to begin continuous arteriovenous hemofiltration (CAVH) as soon as possible. What is the priority action at this time? (24) a. Call the charge nurse and transfer the patient to the ICU. b. Develop a teaching plan for the patient that focuses on CAVH. c. Assist the patient with morning bath and mouth care before transfer. d. Notify the physician that the patient's mean arterial pressure is 68 mm Hg.
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a CAVH is a continuous renal replacement therapy that is prescribed for patients with kidney failure who are critically ill and do not tolerate the rapid shifts in fluids and electrolytes that are associated with hemodialysis. A teaching plan is not urgent at this time. A patient must have a mean arterial pressure (MAP_ of at least 60 mm Hg or more for CAVH to be of use. The physician should be notified about this patient's MAP; it is a priority, but not the highest priority. When a patient urgently needs a procedure, morning care does not take priority and may be deferred until later this day.
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A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should you delegate to a UAP? a. Reminding the patient to change positions slowly b. Assessing the patient for muscle weakness c. Teaching the patient how to collect a 24-hour urine sample d. Revising the patient's nursing plan of care
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a Patients with hypo function of the adrenal gland often have hypotension and should be instructed to change positions slowly. Once a patient has been so instructed, it is appropriate for the UAP to remind the patient of those instructions. Assessing, teaching, and planning nursing care require more education and should be done by licensed nurses.
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Assessment finding for a patient with Cushing disease include all of the following. For which finding would you notify the physician immediately? a. Purple striae present on the abdomen and thighs b. Weight gain of 1lb since the previous day c. Dependent edema rated as 1+ in the ankles and calves d. Crackles bilaterally in the lower lobes of the lungs
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d The presence of crackles int he patient's lungs indicate excess fluid volume due to excess water and sodium reabsorption and may be a symptom of pulmonary edema, which must be treated rapidly. Striae (stretch marks), weight gain, and dependent edema are common findings in patients with Cushing disease. These findings should be monitored but do not require urgent action.
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A patient with pheochromocytoma underwent surgery to remove his adrenal glands. Which nursing intervention should you delegate to a UAP? a. Revising the nursing care plan to include strategies to provide a calm and restful environment postoperatively b. Instructing the patient to avoid smoking and drinking caffeine-containing beverages c. Assessing the patient's skin and mucous membranes for signs of adequate hydration d. Monitoring lying and standing BPs every 4 hours with a cuff placed on the same arm
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d Monitoring vital signs is within the education and scope of practice for UAPs. The nurse should be sure to instruct the UAP that BP measurements are to be taken with the cuff on the same arm each time. Revising the care plan and instructing and assessing patients are beyond the scope of UAPs and fall within the purview of licensed nurses.
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For the patient with pheochromocytoma, which physical assessment technique should you instruct an LPN/LVN to avoid? a. Listening for abdominal bowel sounds in all four quadrants b. Palpating the abdomen in all four quadrants c. Checking the blood pressure every hour d. Assessing the mucous membranes for hydration status
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b Palpating the abdomen can cause the sudden release of catecholamines and severe hypertension.
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A patient with adrenal insufficiency is to be discharged and will take prednisone (Deltasone) 10 mg orally each day. Which instruction would you be sure to teach the patient? a. Excessive weight gain or swelling should be reported to the physician b. Changing positions rapidly may cause hypotension c. A diet with foods low in sodium may be beneficial d. Signs of hypoglycemia may occur while taking this drug.
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a Rapid weight gain and edema are signs of excessive drug therapy, and the dosage of the drug would need to be adjusted. Hypertension, hyponatremia, hyperkalemia, and hyperglycemia are common in patients with adrenal hypofunction.
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You are caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which postoperative finding requires immediate intervention? a. Presence of glucose in the nasal drainage b. Presence of nasal packing in the nares c. Urine output of 40 to 50 mL/hr d. Patient reports of thirst
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a The presence of glucose in nasal drainage indicates that the fluid is CSF and suggests a CSF leak. Packing is normally inserted in the nares after the surgical incision is closed. Urine output of 40 to 50 mL/hr is adequate, and patients may experience thirst postoperatively. When patients are thirsty, nursing staff should encourage fluid intake.
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You are preparing a care plan for a patient with Cushing disease. Which nursing diagnoses would you be sure to include? (Select all that apply.) a. Risk for injury related to the potential for bruising b. Disturbed body image c. Imbalanced nutrition: Less than body requirements d. Risk for injury related to the potential for hypertension e. Risk for Infection
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a, b, d, e A patient with Cushing disease experiences body changes affecting body image and is at risk for bruising, infection, and hypertension. Such a patient usually gains weight.
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When providing care for a patient with Addison disease, you should be alert for which laboratory value change? a. Decreased hematocrit b. Increased sodium level c. Decreased potassium level d. Decreased calcium level
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a A patient with Addison disease is at risk for anemia. The nurse should expect this patient's sodium level to decrease, and potassium and calcium levels to increase.
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A female patient is admitted with a diagnosis of primary hypo function of the adrenal glands. Which assessment finding supports this diagnosis? a. Patchy areas of pigment loss over the face b. Decreased muscle strength c. Greatly increased urine output d. Scalp alopecia
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a Vitiligo, or patchy areas of pigment loss with increased pigmentation and the edges, is seen with primary hypo function of the adrenal glands and is caused by autoimmune destruction of melanocytes in the skin. The other findings are signs of pituitary hypofunction.
question
Two UAPs are assisting a patient with Cushing disease to move up in bed. Which action by the UAPs requires your immediate intervention? a. Positioning themselves on opposite sides of the patient's bed b. Grasping under the patient's arms to pull him up in bed c. Lowering the side rails of the patient's bed before moving him d. Removing the pillow before moving the patient up in bed
answer
b The patient with Cushing disease usually has paper-thin skin that is easily injured. The UAPs should use a lift or draw sheet to carefully move the patient and prevent injury to the skin. All of the other actions are appropriate to moving this patient up in bed.
question
Which health care provider orders for the patient with Addison disease should you delegate to the experienced UAP? (Select all that apply.) a. Weigh the patient every morning b. Obtain fingerstick glucose before each meal and at bedtime c. Check vital signs every 2 hours d. Monitor for cardiac dysrhythmias e. Administer oral prednisone 10 mg every morning f. Record intake and output
answer
a, b, c, f Weighing patients, recording intake and output, and checking vital signs are all within the scope of practice for a UAP. An experienced UAP would have been trained to perform fingerstick glucose monitoring also. Administering medications and monitoring for cardiac dysrhythmias are within the scope of practice for licensed nurses.
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The LPN/LVN asks you why the patient with Cushing disease has bruising and petechiae across her abdomen. What is your best response? a. "Patients with Cushing disease often have bleeding disorders." b. "Patients with Cushing disease have very fragile capillaries." c. "Please ask the patient if she slipped or fell during the night." d. "Thin and delicate skin can result in development of bruising."
answer
b A key cardiovascular feature seen in patients with Cushing disease is capillary fragility, which results in bruising and petechiae. Bleeding disorders are not a sign of Cushing disease, and although these patients have delicate skin, this is not the cause of the bruising. You may want to investigate whether the patient fell, but these patients have bruising and petechiae despite falls.
question
You admit a patient whose assessment reveals prominent brow ridge, large hands and feet, and large lips and nose. Which pituitary hormone do you suspect is elevated? a. TSH b. Growth hormone c. ACTH d. Vasopressin antidiuretic hormone
answer
b These assessment findings are classic initial manifestations for growth hormone excess.
