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A client is taking furosemide (Lasix) for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best?
- A. Assess the client's vital signs
- B. Auscultate heart and breath sounds
- C. Replace the client's abdomen
- D. Assess the client's diet history
Correct Answer: A
Rationale: Furosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds should be assessed if there is fluid retention. The best initial action is to assess vital signs, including weight, to evaluate fluid status.
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A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?
- A. Warm the dialysis solution in a microwave before instillation
- B. Take a sample of the effluent and send to the laboratory
- C. Flush the tubing with normal saline to maintain patency of the catheter
- D. Check the catheter for obstruction
Correct Answer: B
Rationale: An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse.
The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/98 mm Hg, pulse 66 beats/min, and temperature is 98°F (37.6°C). What is the most appropriate action by the nurse?
- A. Administer fluid to increase blood pressure
- B. Monitor the client closely for hypotension
- C. Assess for signs of infection
- D. Continue routine monitoring
Correct Answer: B
Rationale: The blood pressure of 110/98 mm Hg is relatively low post-hemodialysis and could indicate hypotension, a common complication. The most appropriate action is to monitor the client closely for signs of hypotension, such as dizziness or weakness, to ensure stability.
A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema?
- A. Maintaining oxygen saturation of 88%
- B. Minimal crackles in the lungs and lung sounds
- C. Maintaining a balanced intake and output
- D. Limited shortness of breath upon exertion
Correct Answer: C
Rationale: With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Maintaining a balanced intake and output is the most direct goal to prevent fluid overload and reduce the risk of pulmonary edema.
A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time?
- A. Decreased calcium levels
- B. Increased phosphorus levels
- C. No adventitious sounds in the lungs
- D. Increased edema in the legs
Correct Answer: C
Rationale: The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the client's body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.
A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the priority action?
- A. Calculate the mean arterial pressure (MAP)
- B. Ask for insertion of a pulmonary artery catheter
- C. Slow the normal saline infusion
- D. Monitor respiratory rate
Correct Answer: C
Rationale: The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion to prevent worsening of symptoms. Calculating MAP is important but not the priority when shortness of breath is evident. A pulmonary artery catheter is invasive and not the first action. Monitoring respiratory rate is important but secondary to adjusting the infusion.