Nokea
The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should
- A. apply a sterile gauze dressing to maintain sterility.
- B. replace the transparent dressing every 10 days to prevent manipulation.
- C. assess the catheter site for redness and/or swelling.
- D. use the catheter for drawing blood samples to reduce patient discomfort.
Correct Answer: C
Rationale: The correct answer is C because assessing the catheter site for redness and/or swelling is essential in monitoring for signs of infection or complications. Redness and swelling can indicate infection, which requires prompt intervention.
A: Applying a sterile gauze dressing is not necessary for a temporary percutaneous dialysis catheter unless specified by the healthcare provider.
B: Transparent dressings are typically left in place for several days unless there is a specific reason to change them more frequently.
D: Using the catheter for drawing blood samples is not recommended as it can increase the risk of infection and may interfere with the dialysis process.
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Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply.)
- A. Protein
- B. Sodium
- C. Creatinine
- D. Red blood cells
Correct Answer: A
Rationale: The presence of protein in the glomerular filtrate indicates a problem with renal function as healthy kidneys should not allow large molecules like proteins to pass through the filtration barrier. This could be a sign of kidney damage or dysfunction. Sodium, creatinine, and red blood cells are normally present in the filtrate and are not specific indicators of renal function issues. Sodium is actively reabsorbed in the renal tubules, creatinine is a waste product filtered by the kidneys, and a small number of red blood cells may pass through the filtration barrier under normal circumstances.
The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should
- A. not be concerned unless urine output decreases.
- B. evaluate the patient’s serum creatinine for up to 72 hours after the procedure.
- C. obtain an order for a renal ultrasound.
- D. evaluate the patient’s postvoid residual volume to detect intrarenal injury.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Contrast dyes can cause kidney injury due to their nephrotoxic effects.
2. Serum creatinine levels are a reliable indicator of kidney function.
3. Evaluating serum creatinine for up to 72 hours after the procedure allows detection of any contrast-induced kidney injury.
4. Monitoring serum creatinine helps in early identification and intervention for renal complications.
Summary:
A: Incorrect. Urine output alone is not a definitive indicator of kidney injury.
C: Incorrect. Renal ultrasound is not typically used for detecting contrast-induced kidney injury.
D: Incorrect. Postvoid residual volume is not specific for contrast-induced kidney injury.
An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual’s priority action?
- A. Drink additional water to prevent dehydration.
- B. Eat something with 15 g of simple carbohydrates.
- C. Go to the first-aid station to have glucose checked.
- D. Take another dose of the oral agent.
Correct Answer: B
Rationale: The correct answer is B: Eat something with 15 g of simple carbohydrates. In this scenario, the individual is exhibiting signs of hypoglycemia due to the combination of glipizide (which can lower blood sugar) and exercise. The priority action is to raise blood sugar levels quickly to prevent further complications. Consuming simple carbohydrates, like glucose tablets or juice, will rapidly increase blood sugar levels. This is crucial to prevent the individual from passing out or experiencing more serious consequences.
Choice A is incorrect because while hydration is important, it is not the immediate priority in this situation. Choice C is incorrect as going to the first-aid station may waste valuable time when immediate action is needed. Choice D is incorrect as taking another dose of the oral agent can further lower blood sugar levels and worsen the hypoglycemia.
A normal glomerular filtration rate is
- A. less than 80 mL/min.
- B. 80 to 125 mL/min.
- C. 125 to 180 mL/min.
- D. more than 189 mL/min.
Correct Answer: B
Rationale: The correct answer is B (80 to 125 mL/min) because this range represents the normal glomerular filtration rate (GFR) for a healthy adult. GFR indicates the rate at which blood is filtered by the kidneys, with 125 mL/min being the average value. Values below 80 mL/min (Choice A) suggest impaired kidney function, while values above 189 mL/min (Choice D) may indicate hyperfiltration or underlying conditions. Choice C (125 to 180 mL/min) falls within the normal range, but the typical average is around 125 mL/min. Thus, choice B is the correct answer as it reflects the standard GFR range for adults.
Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.)
- A. Administer levothyroxine as prescribed.
- B. Encourage the intake of foods high in sodium.
- C. Initiate passive rewarming interventions.
- D. Monitor airway and respiratory effort.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Administering levothyroxine is crucial in treating myxedema coma as it helps replace the deficient thyroid hormone.
2. This intervention addresses the underlying cause of myxedema coma, which is severe hypothyroidism.
3. Levothyroxine administration can help reverse the symptoms of myxedema coma and improve the patient's condition.
Summary of Incorrect Choices:
- B: Encouraging high sodium intake is not appropriate as myxedema coma is associated with fluid retention and sodium may exacerbate this.
- C: Passive rewarming interventions are not relevant for myxedema coma, as the condition is not typically related to hypothermia.
- D: While monitoring airway and respiratory effort is important in general patient care, it is not a specific intervention for myxedema coma.