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A client who underwent surgery and experienced significant blood loss is being cared for by a nurse. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.)
- A. Urine output of 100 mL in 4 hours
- B. Large amount of sediment in the urine
- C. A & B
- D. Amber, odorless urine
Correct Answer: C
Rationale: The nurse must monitor for signs of acute kidney injury in a postoperative client who had major blood loss. Low urine output, presence of sediment in the urine, and low blood pressure should raise concerns and be reported to the healthcare provider promptly. Postoperatively, assessing urine characteristics is crucial. Sediment, hematuria, and urine output less than 0.5 mL/kg/hour for 3 to 4 hours should be reported. While a urine output of 100 mL in 4 hours is low, it should be compared to the recommended 0.5 mL/kg/hour over a longer period. Perfusion to the kidneys is a priority, hence the importance of addressing low blood pressure. Amber, odorless urine is considered normal and does not indicate an immediate concern for acute kidney injury, unlike low urine output and presence of sediment.
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A client has a urine specific gravity of 1.040. What action should the nurse take?
- A. Obtain a urine culture and sensitivity.
- B. Place the client on restricted fluids.
- C. Assess the client's creatinine level.
- D. Increase the client's fluid intake.
Correct Answer: D
Rationale: A urine specific gravity of 1.040 is higher than the normal range (1.005 to 1.030) and can indicate dehydration, decreased kidney blood flow, or the presence of antidiuretic hormone. In this situation, the priority action should be to increase the client's fluid intake to address the high specific gravity. Obtaining a urine culture, placing the client on restricted fluids, or assessing the creatinine level would not directly address the underlying issue of high urine specific gravity caused by dehydration or other factors.
A client's baseline vital signs are temperature 98°F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever to 103°F. Which of the following respiratory rates would the nurse anticipate as part of the body's response to the change in client status?
- A. 12 breaths/min
- B. 16 breaths/min
- C. 18 breaths/min
- D. 22 breaths/min
Correct Answer: D
Rationale: When a client experiences a fever, there is an increase in body temperature, leading to a higher metabolic rate and oxygen demand. As a result, the respiratory rate typically increases to meet the body's increased oxygen needs. Therefore, in response to the fever spike from 98°F to 103°F, the nurse would anticipate a higher respiratory rate. Choices A, B, and C are incorrect because a decrease in body temperature, not an increase as seen in fever, would lead to a decrease in respiratory rate to conserve energy and oxygen consumption.
A middle-aged female client with diabetes mellitus is being treated for the third episode of acute pyelonephritis in the past year. The client asks, 'What can I do to help prevent these infections?' How should the nurse respond?
- A. Test your urine daily for the presence of ketone bodies and proteins.
- B. Use tampons rather than sanitary napkins during your menstrual period.
- C. Drink more water and empty your bladder more frequently during the day.
- D. Keep your hemoglobin A1c under 9% by controlling your blood sugar levels.
Correct Answer: C
Rationale: The correct answer is C. Clients with long-standing diabetes mellitus are at risk for pyelonephritis due to various reasons. Elevated blood glucose levels in diabetes can lead to glucose spilling into the urine, altering the pH and creating a conducive environment for bacterial growth. Neuropathy associated with diabetes can reduce bladder tone and diminish the sensation of bladder fullness, resulting in less frequent voiding and increased risk of stasis and bacterial overgrowth. Increasing fluid intake, particularly water, and voiding regularly can help prevent stasis and microbial overgrowth. Testing urine for ketones and proteins or using tampons instead of sanitary napkins are not effective strategies for preventing pyelonephritis. Keeping the hemoglobin A1c levels below 9% is crucial for managing diabetes, but it alone does not directly prevent pyelonephritis.
A healthcare professional is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted as the most specific indicator of this disease?
- A. Hemoglobin
- B. Serum bilirubin
- C. Blood urea nitrogen (BUN)
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: B
Rationale: Serum bilirubin is the most specific indicator of hepatitis as it reflects liver dysfunction. Hemoglobin, blood urea nitrogen (BUN), and erythrocyte sedimentation rate (ESR) are not specific to hepatitis. Hemoglobin measures the oxygen-carrying capacity of red blood cells, BUN evaluates kidney function, and ESR is a nonspecific marker of inflammation or infection.
A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon's office? Select all that apply.
- A. Hematocrit 30%
- B. Sodium 141 mEq/L
- C. Hemoglobin 8.9 g/dL
- D. Platelets 210,000 cells/mm3
Correct Answer: C
Rationale: The correct answer is C. Hemoglobin level of 8.9 g/dL is below the normal range, indicating anemia. Anemia can affect the body's ability to carry oxygen, impacting surgical outcomes. Hematocrit level is an indirect measure of red blood cells, which also reveals anemia when low. Sodium level of 141 mEq/L and platelet count of 210,000 cells/mm3 are within normal ranges and do not require immediate reporting. Abnormal sodium levels can lead to various issues, but in this scenario, it is not a concern for surgical readiness. Platelet count is vital for blood clotting, and a count of 210,000 cells/mm3 is considered normal, so it does not need urgent attention.