Nokea
The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate?
- A. Oral intake
- B. Pain intensity
- C. Level of consciousness
- D. Radiation of pain
Correct Answer: C
Rationale: Bleeding is a major complication of kidney surgery. If undetected and untreated, this can result in hypovolemia and hemorrhagic shock. The nurses role is to observe for these complications, to report their signs and symptoms, and to administer prescribed parenteral fluids and blood and blood components. Monitoring of vital signs, skin condition, the urinary drainage system, the surgical incision, and the level of consciousness is necessary to detect evidence of bleeding, decreased circulating blood, and fluid volume and cardiac output. Bleeding is not normally evidenced by changes in pain or oral intake.
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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.
A 71-year-old patient with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The patient tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make?
- A. The decision is certainly yours to make, but be sure not to make a mistake.
- B. Kidney transplants in patients your age are as successful as they are in younger patients.
- C. I understand your hesitancy to commit to a transplant surgery. Success is comparatively rare.
- D. Have you talked this over with your family?
Correct Answer: B
Rationale: Although there is no specific age limitation for renal transplantation, concomitant disorders (e.g., coronary artery disease, peripheral vascular disease) have made it a less common treatment for the elderly. However, the outcome is comparable to that of younger patients. The other listed options either belittle the patient or give the patient misinformation.
The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time?
- A. Only when needed
- B. Daily at bedtime
- C. First thing in the morning
- D. With each meal
Correct Answer: D
Rationale: Both calcium carbonate and calcium acetate are medications that bind with the phosphate and assist in excreting the phosphate from the body, in turn lowering the phosphate levels. Phosphate-binding medications must be administered with food to be effective.
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.
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.