Nokea
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.
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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 client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse?
- A. Use the catheter for the next laboratory blood draw
- B. Monitor the central venous pressure through this line
- C. Access the line for the next intravenous medication
- D. Place a heparin or heparin/saline dwell after hemodialysis
Correct Answer: D
Rationale: The central line should have a heparin or heparin/saline dwell after hemodialysis treatment to prevent clotting. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids.
A client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Which nurse should be assigned to this client for continuity of care?
- A. A new graduate nurse
- B. A float nurse from another unit
- C. The registered nurse (RN) previously assigned to this client
- D. A licensed practical nurse (LPN)
Correct Answer: C
Rationale: Continuity of care is important to assess subtle differences in clients. Therefore, the registered nurse (RN) who was assigned to this client previously should again give care to this client. The first nurses would not be as knowledgeable about the unit and its clients. The licensed practical nurse may not have the education level of the RN to assess for pericarditis.
A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse?
- A. Discuss what the treatment regimen means to him
- B. Refer the client to a mental health nurse practitioner
- C. Reschedule the appointments to another date and time
- D. Discuss the option of peritoneal dialysis
Correct Answer: A
Rationale: The initial action for the nurse is to assess anxiety, coping styles, and the client's acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all options to assess the client, the client's acceptance of the treatment should come first.
Dialysis works using the passive transfer of toxins by diffusion. Which statement by the client indicates a need for further teaching?
- A. Dialysis removes waste through osmosis
- B. Dialysis moves toxins from high to low concentration
- C. Dialysis uses a semipermeable membrane
- D. Dialysis helps balance electrolytes
Correct Answer: A
Rationale: Dialysis works by diffusion, not osmosis. The client's statement about osmosis indicates a misunderstanding, as osmosis refers to water movement, whereas dialysis involves the movement of toxins and solutes across a semipermeable membrane from an area of higher to lower concentration.