Nokea
The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurses most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurses best response?
- A. Assess the patient for signs of bleeding and inform the physician.
- B. Monitor the patients vital signs every 15 minutes for the next hour.
- C. Reposition the patient and reassess vital signs.
- D. Palpate the patients flanks for pain and inform the physician.
Correct Answer: A
Rationale: Bleeding may be suspected when the patient experiences fatigue and when urine output is less than 30 mL/h. The physician must be made aware of this finding promptly. Palpating the patients flanks would cause intense pain that is of no benefit to assessment.
You may also like to solve these questions
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.
A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason?
- A. Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.
- B. Intake and output calculations are essential and the laboratory will calculate the precise urine output produced by this patient.
- C. A creatinine clearance study may be ordered at a later time and the laboratory will hold all urine until it is determined if the test will be necessary.
- D. There is great concern about electrolyte imbalances and the laboratory will monitor the urine for changes in potassium and sodium concentrations.
Correct Answer: A
Rationale: Hematuria is the most common manifestation of renal trauma; its presence after trauma suggests renal injury. Hematuria may not occur, or it may be detectable only on microscopic examination. All urine should be saved and sent to the laboratory for analysis to detect RBCs and to evaluate the course of bleeding. Measuring intake and output is not a function of the laboratory. The laboratory does not save urine to test creatinine clearance at a later time. The laboratory does not monitor the urine for sodium or potassium concentrations.
The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula?
- A. A vein and an artery in your arm will be attached surgically.
- B. The arm should be immobilized for 4 to 6 days.
- C. One needle will be inserted into the fistula for each dialysis treatment.
- D. The fistula can be used 2 days after the surgery for dialysis treatment.
Correct Answer: A
Rationale: The fistula joins an artery and a vein, either side-to-side or end-to-end. This access will need time, usually 2 to 3 months, to mature before it can be used. The patient is encouraged to perform exercises to increase the size of the affected vessels (e.g., squeezing a rubber ball for forearm fistulas). Two needles will be inserted into the fistula for each dialysis treatment.
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 providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants risks of renal carcinoma?
- A. Avoiding heavy alcohol use
- B. Control of sodium intake
- C. Smoking cessation
- D. Adherence to recommended immunization schedules
Correct Answer: C
Rationale: Tobacco use is a significant risk factor for renal cancer, surpassing the significance of high alcohol and sodium intake. Immunizations do not address an individuals risk of renal cancer.