Nokea
The nurse is caring for a patient status after a motor vehicle accident. The patient has developed AKI. What is the nurses role in caring for this patient? Select all that apply.
- A. Providing emotional support for the family
- B. Monitoring for complications
- C. Participating in emergency treatment of fluid and electrolyte imbalances
- D. Providing nursing care for primary disorder (trauma)
- E. Directing nutritional interventions
Correct Answer: A,B,C,D
Rationale: The nurse has an important role in caring for the patient with AKI. The nurse monitors for complications, participates in emergency treatment of fluid and electrolyte imbalances, assesses the patients progress and response to treatment, and provides physical and emotional support. Additionally, the nurse keeps family members informed about the patients condition, helps them understand the treatments, and provides psychological support. Although the development of AKI may be the most serious problem, the nurse continues to provide nursing care indicated for the primary disorder (e.g., burns, shock, trauma, obstruction of the urinary tract). The nurse does not direct the patients nutritional status; the dietician and the physician normally collaborate on directing the patients nutritional status.
You may also like to solve these questions
A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action?
- A. Inform the physician and assess the patient for signs of infection.
- B. Flush the peritoneal catheter with normal saline.
- C. Remove the catheter promptly and have the catheter tip cultured.
- D. Administer a bolus of IV normal saline as ordered.
Correct Answer: A
Rationale: Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary care provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the physician would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection.
A patient has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m^2. Based on this GFR, the nurse interprets that the patients chronic kidney disease is at what stage?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: C
Rationale: Stages of chronic renal failure are based on the GFR. Stage 3 is defined by a GFR in the range of 30 to 59 mL/min/1.73 m^2. This is considered a moderate decrease in GFR.
A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care?
- A. Ensure that the patient moves the extremity with the vascular access site as little as possible.
- B. Change the dressing over the vascular access site at least every 12 hours.
- C. Utilize the vascular access site for infusion of IV fluids.
- D. Assess for a thrill or bruit over the vascular access site each shift.
Correct Answer: D
Rationale: The bruit, or thrill, over the venous access site must be evaluated at least every shift. Frequent dressing changes are unnecessary and the patient does not normally need to immobilize the site. The site must not be used for purposes other than dialysis.
The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)?
- A. Hypernatremia
- B. Hypomagnesemia
- C. Hyperkalemia
- D. Hypercalcemia
Correct Answer: C
Rationale: Hyperkalemia, a common complication of acute kidney injury, is life-threatening if immediate action is not taken to reverse it. The administration of polystyrene sulfonate reduces serum potassium levels.
A patient on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurses most recent assessments indicate that the patient is producing copious quantities of dilute urine. What is the nurses most appropriate response?
- A. Assess the patient for further signs or symptoms of rejection.
- B. Recognize this as an expected finding.
- C. Inform the primary care provider of this finding.
- D. Administer exogenous antidiuretic hormone as ordered.
Correct Answer: B
Rationale: A kidney from a living donor related to the patient usually begins to function immediately after surgery and may produce large quantities of dilute urine. This is not suggestive of rejection and treatment is not warranted. There is no obvious need to report this finding.