Nokea
The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern?
- A. Headache and nausea
- B. Scant blood on the AV fistula
- C. Potassium 3.7 mEq/L (mmol/L) [3.5-5.0 mEq/L, mmol/L]
- D. Hemoglobin 8.8 g/dL [Male: 14-18 g/dL; Female: 12-16 g/dL, Female 115-155 g/L Male 125-170 g/L]
Correct Answer: A
Rationale: Headache and nausea may indicate dialysis disequilibrium syndrome, a serious complication requiring immediate attention.
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The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PHCP)?
- A. WBC 19,000 mm3 [5,000-10,000 mm3]
- B. Hemoglobin 9 g/dL [Male: 14-18 g/dL (140-180 g/L) Female: 12-16 g/dL (120-160 g/L)]
- C. Calcium 8.6 mg/dL [9.0-10.5 mg/dL]
- D. Serum pH 7.33 [7.35-7.45]
Correct Answer: A
Rationale: Elevated WBC (19,000 mm3) suggests infection, a serious complication in peritoneal dialysis.
The oncoming nurse learns that her new patient is suffering from Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion. Which of the following nursing actions is the most important?
- A. Assess the patient's mental status
- B. Provide oral hygiene
- C. Keep accurate intake and output measurements
- D. Reduce stress and discomfort
Correct Answer: A
Rationale: SIADH causes hyponatremia, which can lead to neurological changes, making mental status assessment critical.
A nurse on a medical-surgical unit cares for a client who has just undergone a procedure for a Kock pouch as a treatment for bladder cancer. The initial nursing interventions for this client would include:
- A. Monitoring urine output, checking for indications of ostomy pouch leaks, and noting the size, shape, and color of the stoma.
- B. Speaking to the client's family and updating them regarding the client's status.
- C. Educating the client about stoma care and skincare.
- D. Irrigating the catheters as needed.
Correct Answer: A
Rationale: Initial interventions for a Kock pouch include monitoring urine output and stoma condition to ensure proper function and detect complications.
The nurse is caring for a client with end-stage renal disease who receives prescribed sevelamer. Which of the following findings would indicate a therapeutic response?
- A. Decreased serum calcium levels
- B. Increased hemoglobin and hematocrit
- C. Decreased serum potassium levels
- D. Decreased serum phosphorus levels
Correct Answer: D
Rationale: Sevelamer is a phosphate binder used to lower serum phosphorus levels in end-stage renal disease, making decreased phosphorus levels the therapeutic response. It does not directly affect calcium (A), hemoglobin/hematocrit (B), or potassium (C).
The nurse has taught a client about a scheduled intravenous (IV) urography (pyelogram). Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I should expect a temporary urinary catheter inserted during the procedure.
- B. I will take a laxative the night before to clear my bowels.
- C. I must fill my bladder with water immediately before the procedure.
- D. I may experience blood in my urine for a few days after this procedure.
Correct Answer: B
Rationale: A laxative is often required before IV urography to clear the bowels for better imaging.