Nokea
A patient is being treated for AKI and the patient daily weights have been ordered. The nurse notes a weight gain of 3 pounds over the past 48 hours. What nursing diagnosis is suggested by this assessment finding?
- A. Imbalanced nutrition: More than body requirements
- B. Excess fluid volume
- C. Sedentary lifestyle
- D. Adult failure to thrive
Correct Answer: B
Rationale: If the patient with AKI gains or does not lose weight, fluid retention should be suspected. Short-term weight gain is not associated with excessive caloric intake or a sedentary lifestyle. Failure to thrive is not associated with weight gain.
You may also like to solve these questions
The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?
- A. Using a stethoscope for auscultating the fistula is contraindicated.
- B. The patient feels best immediately after the dialysis treatment.
- C. Taking a BP reading on the affected arm can damage the fistula.
- D. The patient should not feel pain during initiation of dialysis.
Correct Answer: C
Rationale: When blood flow is reduced through the access for any reason (hypotension, application of BP cuff/tourniquet), the access site can clot. Auscultation of a bruit in the fistula is one way to determine patency. Typically, patients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, a needle stick is still painful.
The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula?
- A. A vein and an artery in your arm will be attached surgically.
- B. The arm should be immobilized for 4 to 6 days.
- C. One needle will be inserted into the fistula for each dialysis treatment.
- D. The fistula can be used 2 days after the surgery for dialysis treatment.
Correct Answer: A
Rationale: The fistula joins an artery and a vein, either side-to-side or end-to-end. This access will need time, usually 2 to 3 months, to mature before it can be used. The patient is encouraged to perform exercises to increase the size of the affected vessels (e.g., squeezing a rubber ball for forearm fistulas). Two needles will be inserted into the fistula for each dialysis treatment.
A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason?
- A. Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.
- B. Intake and output calculations are essential and the laboratory will calculate the precise urine output produced by this patient.
- C. A creatinine clearance study may be ordered at a later time and the laboratory will hold all urine until it is determined if the test will be necessary.
- D. There is great concern about electrolyte imbalances and the laboratory will monitor the urine for changes in potassium and sodium concentrations.
Correct Answer: A
Rationale: Hematuria is the most common manifestation of renal trauma; its presence after trauma suggests renal injury. Hematuria may not occur, or it may be detectable only on microscopic examination. All urine should be saved and sent to the laboratory for analysis to detect RBCs and to evaluate the course of bleeding. Measuring intake and output is not a function of the laboratory. The laboratory does not save urine to test creatinine clearance at a later time. The laboratory does not monitor the urine for sodium or potassium concentrations.
A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient?
- A. Increasing oral intake
- B. Managing postoperative pain
- C. Managing dialysis
- D. Increasing mobility
Correct Answer: B
Rationale: The patient requires frequent analgesia during the postoperative period and assistance with turning, coughing, use of incentive spirometry, and deep breathing to prevent atelectasis and other pulmonary complications. Increasing oral intake and mobility are not priority nursing actions in the immediate postoperative care of this patient. Dialysis is not necessary following kidney surgery.
A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patients care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include?
- A. Constipation related to immobility
- B. Risk for injury related to altered thought processes
- C. Hyperthermia related to the inflammatory process
- D. Excess fluid volume related to generalized edema
Correct Answer: D
Rationale: The major clinical manifestation of nephrotic syndrome is edema, so the appropriate nursing diagnosis is Excess fluid volume related to generalized edema. Edema is usually soft, pitting, and commonly occurs around the eyes, in dependent areas, and in the abdomen.