Nokea
The nurse has identified the nursing diagnosis of risk for infection in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk?
- A. Maintain aseptic technique when administering dialysate.
- B. Wash the skin surrounding the catheter site with soap and water prior to each exchange.
- C. Add antibiotics to the dialysate as ordered.
- D. Administer prophylactic antibiotics by mouth or IV as ordered.
Correct Answer: A
Rationale: Aseptic technique is used to prevent peritonitis and other infectious complications of peritoneal dialysis. It is not necessary to cleanse the skin with soap and water prior to each exchange. Antibiotics may be added to dialysate to treat infection, but they are not used to prevent infection.
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A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patients abdomen is increasing in girth. What is the nurses most appropriate action?
- A. Advance the catheter 2 to 4 cm further into the peritoneal cavity.
- B. Reposition the patient to facilitate drainage.
- C. Aspirate from the catheter using a 60-mL syringe.
- D. Infuse 50 mL of additional dialysate.
Correct Answer: B
Rationale: If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the patient from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. It would be unsafe to aspirate or to infuse more dialysate.
A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event?
- A. Psychosocial stress
- B. Hypersensitivity to an immunization
- C. Menarche
- D. Streptococcal infection
Correct Answer: D
Rationale: Postinfectious causes of postinfectious glomerular disease are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks. Menarche, stress, and hypersensitivity are not typical causes.
A patient has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the patient about what topic?
- A. Typical diet
- B. Allergy status
- C. Psychosocial stressors
- D. Current medication use
Correct Answer: D
Rationale: The kidneys are susceptible to the adverse effects of medications because they are repeatedly exposed to substances in the blood. Nephrotoxic medications are a more likely cause of AKI than diet, allergies, or stress.
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.
The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize?
- A. Assessment of the quantity of the patients urine output
- B. Assessment of the patients' incision
- C. Assessment of the patients' abdominal girth
- D. Assessment for flank or abdominal pain
Correct Answer: A
Rationale: After kidney transplantation, the nurse should perform all of the listed assessments. However, oliguria is considered to be more suggestive of rejection than changes to the patients abdomen or incision.