Nokea
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.
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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 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 in the intensive care unit is started on continuous venous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse?
- A. Blood leak detector alarm
- B. Low ultrafiltrate volume
- C. High venous pressure
- D. Low arterial pressure
Correct Answer: A
Rationale: A blood leak detector alarm indicates a potential rupture in the dialysis membrane, which is a critical issue requiring immediate action to stop the procedure and ensure patient safety. Low ultrafiltrate volume, high venous pressure, or low arterial pressure may require adjustments but are not as immediately life-threatening.
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.
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.