Nokea
The nurse is caring for a patient who has just returned to the post-surgical unit following renal surgery. When assessing the patients output from surgical drains, the nurse should assess what parameters? Select all that apply.
- A. Quantity of output
- B. Color of the output
- C. Visible characteristics of the output
- D. Odor of the output
- E. pH of the output
Correct Answer: A,B,C
Rationale: Urine output and drainage from tubes inserted during surgery are monitored for amount, color, and type or characteristics. Odor and pH are not normally assessed.
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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.
The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD?
- A. A patient with a history of polycystic kidney disease
- B. A patient with diabetes mellitus and poorly controlled hypertension
- C. A patient who is morbidly obese with a history of vascular disorders
- D. A patient with severe chronic obstructive pulmonary disease
Correct Answer: B
Rationale: Systemic diseases, such as diabetes mellitus (leading cause); hypertension; chronic glomerulonephritis; pyelonephritis; obstruction of the urinary tract; hereditary lesions, such as in polycystic kidney disease; vascular disorders; infections; medications; or toxic agents may cause ESKD. A patient with more than one of these risk factors is at the greatest risk for developing ESKD. Therefore, the patient with diabetes and hypertension is likely at highest risk for ESKD.
A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurses care of this patient?
- A. The disease is self-limiting and cysts usually resolve spontaneously in the fifth or sixth decade of life.
- B. The patients disease is incurable and the nurses interventions will be supportive.
- C. The patient will eventually require surgical removal of his or her renal cysts.
- D. The patient is likely to respond favorably to lithotripsy treatment of the cysts.
Correct Answer: B
Rationale: PKD is incurable and care focuses on support and symptom control. It is not self-limiting and is not treated surgically or with lithotripsy.
A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patients care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include?
- A. Constipation related to immobility
- B. Risk for injury related to altered thought processes
- C. Hyperthermia related to the inflammatory process
- D. Excess fluid volume related to generalized edema
Correct Answer: D
Rationale: The major clinical manifestation of nephrotic syndrome is edema, so the appropriate nursing diagnosis is Excess fluid volume related to generalized edema. Edema is usually soft, pitting, and commonly occurs around the eyes, in dependent areas, and in the abdomen.
The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)?
- A. The patient is complains of an inability to initiate voiding.
- B. The patients urine is cloudy with a foul odor.
- C. The patients average urine output has been 10 mL/hr for several hours.
- D. The patient complains of acute flank pain.
Correct Answer: C
Rationale: Oliguria (<500 mL/d of urine) is the most common clinical situation seen in AKI. Flank pain and inability to initiate voiding are not characteristic of AKI. Cloudy, foul-smelling urine is suggestive of a urinary tract infection.