Nokea
The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be monitored closely?
- A. Serum potassium
- B. Hemoglobin
- C. Serum sodium
- D. White blood cell count
Correct Answer: A
Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is undergoing erythropoietin therapy, monitoring serum potassium levels is crucial. Erythropoietin can stimulate red blood cell production, which may lead to an increase in potassium levels, predisposing the client to hyperkalemia. Monitoring serum potassium levels helps in early detection of hyperkalemia and appropriate intervention. Choices B, C, and D are incorrect because although hemoglobin, serum sodium, and white blood cell count are important parameters to monitor in various clinical conditions, they are not specifically associated with erythropoietin therapy in chronic kidney disease.
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A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which intervention should the nurse implement first?
- A. Administer intravenous calcium gluconate.
- B. Administer intravenous insulin and glucose.
- C. Administer intravenous sodium bicarbonate.
- D. Administer a loop diuretic as prescribed.
Correct Answer: B
Rationale: The correct answer is B: Administer intravenous insulin and glucose. In the presence of hyperkalemia, the priority intervention is to shift potassium back into the cells to lower serum levels. Insulin, in combination with glucose, helps drive potassium intracellularly. Administering calcium gluconate (choice A) is used to stabilize myocardial cell membranes but does not address the underlying cause of hyperkalemia. Administering sodium bicarbonate (choice C) is not the initial treatment for hyperkalemia. Loop diuretics (choice D) may be used later to enhance potassium excretion but are not the primary intervention for acute hyperkalemia.
While auscultating a client's heart sounds, which description should the nurse use to document a swishing sound related to blood turbulence or valvular defect?
- A. S1 S2
- B. S1 S2 S3
- C. Murmur
- D. Pericardial friction rub
Correct Answer: C
Rationale: The correct answer is 'C: Murmur.' A murmur is auscultated as a swishing sound associated with blood turbulence caused by the heart or a valvular defect. Choices 'A: S1 S2' and 'B: S1 S2 S3' refer to normal heart sounds, specifically the closure of heart valves. 'D: Pericardial friction rub' is a dry, rubbing or grating sound caused by inflammation of the pericardial sac and is not associated with blood flow or valvular issues.
A client with liver cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?
- A. Serum albumin of 3.0 g/dL
- B. Bilirubin of 3.0 mg/dL
- C. Ammonia level of 80 mcg/dL
- D. Prothrombin time of 18 seconds
Correct Answer: C
Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.
A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during a prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?
- A. Leakage around the catheter insertion site.
- B. Pink-tinged urine in the drainage bag.
- C. Client reports discomfort at the catheter site.
- D. Decreased urine output in the last hour.
Correct Answer: A
Rationale: The correct answer is A. Leakage around the catheter insertion site may indicate a problem with the catheter placement or function, requiring immediate intervention. Pink-tinged urine in the drainage bag is expected due to the continuous bladder irrigation. Discomfort at the catheter site is common after the procedure. Decreased urine output in the last hour may be due to the continuous bladder irrigation and doesn't require immediate intervention.
A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which intervention should the nurse implement first?
- A. Administer intravenous calcium gluconate.
- B. Administer intravenous insulin and glucose.
- C. Administer intravenous sodium bicarbonate.
- D. Administer a loop diuretic as prescribed.
Correct Answer: B
Rationale: The correct answer is to administer intravenous insulin and glucose first. This intervention helps drive potassium back into the cells, lowering serum levels effectively. Administering intravenous calcium gluconate (choice A) is used to stabilize cardiac membranes in severe hyperkalemia but does not address the underlying cause. Administering intravenous sodium bicarbonate (choice C) is used in metabolic acidosis, not hyperkalemia. Administering a loop diuretic (choice D) can help eliminate potassium but is not the first-line treatment for hyperkalemia in CKD.