Nokea
A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client's care?
- A. Edema and pain
- B. Electrolyte and fluid imbalance
- C. Cardiac and respiratory status
- D. Mental health status
Correct Answer: B
Rationale: The client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client's cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.
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A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 100/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply)
- A. Adjust the rate of extracorporeal blood flow
- B. Place the client in the Trendelenburg position
- C. Administer oxygen therapy
- D. Administer a 250-mL bolus of normal saline
- E. Contact the health care provider for orders
Correct Answer: A,B,D
Rationale: Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Adjusting the extracorporeal blood flow, placing the client in the Trendelenburg position, and administering a normal saline bolus can help stabilize blood pressure.
A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago. What is the priority assessment?
- A. Assess blood pressure for hypotension
- B. Assess skin turgor for dehydration
- C. Auscultate lung sounds for crackles
- D. Monitor daily weight for fluid retention
Correct Answer: A
Rationale: By taking blood pressure, the nurse is assessing for hypotension that could compromise perfusion to the new kidney. The nurse then should notify the provider immediately. Skin turgor, lung sounds, and weight could give information about the fluid status of the client, but they are not the priority assessment.
The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury. Which condition would the nurse expect to find in the client's recent history?
- A. Myelonephritis
- B. Myocardial infarction
- C. Kidney stones
- D. Septic shock
Correct Answer: B
Rationale: Myocardial infarction can lead to decreased cardiac output, reducing renal perfusion and causing pre-renal acute kidney injury. Myelonephritis and kidney stones are more associated with intrinsic or post-renal causes, respectively, while septic shock could also contribute but is less specific in this context.
A client who returned from kidney transplantation 12 hours ago has low urine output, sediment, and hematuria. What should the nurse do?
- A. Report findings to the provider
- B. Monitor intake and output
- C. Assess urine characteristics
- D. Continue routine monitoring
Correct Answer: A
Rationale: The low urine output, sediment, and hematuria should be reported to the provider, as these could indicate complications such as rejection or obstruction in the newly transplanted kidney.
A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?
- A. Check the client's digoxin level
- B. Administer an anti-nausea medication
- C. Ask if the client is able to eat crackers
- D. Ask if referral to a gastroenterologist is needed
Correct Answer: A
Rationale: The signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication. Administering antiemetics, asking if the client can eat, and obtaining a referral to a specialist all address the client's symptoms but do not lead to the cause of the symptoms.