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The nurse is caring for a patient with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply.
- A. Percuss for pain in the right lower abdominal quadrant.
- B. Assess for the presence of peripheral edema.
- C. Auscultate the patients apical heart rate for dysrhythmias.
- D. Assess the patients BP.
- E. Assess the patients orientation and judgment.
Correct Answer: B,D
Rationale: Most patients with acute glomerular inflammation have some degree of edema and hypertension. Dysrhythmias, RLQ pain, and changes in mental status are not among the most common manifestations of acute glomerular inflammation.
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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.
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.
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.
The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patients siblings, parents, and grandparents. This assessment addresses the patients risk of what kidney disorder?
- A. Nephritic syndrome
- B. Acute glomerulonephritis
- C. Nephrotic syndrome
- D. Polycystic kidney disease (PKD)
Correct Answer: D
Rationale: PKD is a genetic disorder characterized by the growth of numerous cysts in the kidneys. Nephritic syndrome, acute glomerulonephritis, and nephrotic syndrome are not genetic disorders.
The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?
- A. Using a stethoscope for auscultating the fistula is contraindicated.
- B. The patient feels best immediately after the dialysis treatment.
- C. Taking a BP reading on the affected arm can damage the fistula.
- D. The patient should not feel pain during initiation of dialysis.
Correct Answer: C
Rationale: When blood flow is reduced through the access for any reason (hypotension, application of BP cuff/tourniquet), the access site can clot. Auscultation of a bruit in the fistula is one way to determine patency. Typically, patients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, a needle stick is still painful.