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The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding?
- A. Woman with a blood pressure of 158/90 mm Hg
- B. Client with Kussmaul respirations
- C. Man with skin itching from head to toe
- D. Client with halitosis and stomatitis
Correct Answer: B
Rationale: The correct answer is B. Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs, a compensatory mechanism for metabolic acidosis common in CKD. Hypertension, as in choice A, is a common finding in CKD due to volume overload and activation of the renin-angiotensin-aldosterone system. Skin itching, as in choice C, is related to calcium-phosphate imbalances seen in CKD. Halitosis and stomatitis, as in choice D, are common in CKD due to uremia, leading to the formation of ammonia. However, Kussmaul respirations indicate a more urgent need for assessment as they suggest impending respiratory distress and metabolic derangement, requiring immediate attention.
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The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client's recent history?
- A. Pyelonephritis
- B. Myocardial infarction
- C. Bladder cancer
- D. Kidney stones
Correct Answer: B
Rationale: In pre-renal acute kidney injury, there is a decrease in perfusion to the kidneys. Myocardial infarction can lead to decreased blood flow to the kidneys, causing pre-renal AKI. Pyelonephritis is an intrinsic/intrarenal cause of AKI involving kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI due to urinary flow obstruction, not related to perfusion issues seen in pre-renal AKI.
A client has the following arterial blood gas (ABG) results: pH 7.51, PCO2 31 mm Hg, PO2 94 mm Hg, HCO3 24 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The ABG results show a pH above the normal range (7.35-7.45) and a decreased PCO2, indicating respiratory alkalosis. In respiratory alkalosis, the pH is increased and the PCO2 is decreased. Metabolic acidosis (choice A) would present with a low pH and low HCO3 levels. Metabolic alkalosis (choice B) would show an increased pH and HCO3 levels. Respiratory acidosis (choice C) would have a low pH and an increased PCO2.
A client who is mouth breathing is receiving oxygen by face mask. The nursing assistant asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to:
- A. Prevent the client from getting a nosebleed
- B. Give the client added fluid by way of the respiratory tree
- C. Humidify the oxygen that is bypassing the client's nose
- D. Prevent fluid loss from the lungs during mouth breathing
Correct Answer: C
Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. When a client breathes through the mouth, the oxygen delivered by the face mask bypasses the natural humidification provided by the nasal passages. Therefore, the water bottle attachment helps to add moisture to the oxygen, preventing dryness and irritation to the respiratory tract. Choices A, B, and D are incorrect. Clients breathing through the mouth are not at risk for nosebleeds, do not receive added fluid through the respiratory tree, and do not experience fluid loss from the lungs due to mouth breathing.
A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication that:
- A. The tube is patent
- B. There is probably a kink in the tubing
- C. Suction should be added to the system
- D. The client is retaining airway secretions
Correct Answer: A
Rationale: The correct answer is A: 'The tube is patent.' When the fluid in the water seal chamber rises and falls during inspiration and expiration, it indicates that the chest tube is patent, allowing for proper drainage. Choice B is incorrect because a kink in the tubing would obstruct the flow of fluid, leading to abnormal fluctuations in the water seal chamber. Choice C is incorrect as adding suction to the system is not indicated based on the described finding. Choice D is incorrect as the rising and falling of fluid in the water seal chamber is not indicative of the client retaining airway secretions.
During a paracentesis procedure on a client with abdominal ascites, into which position would the nurse assist the client?
- A. Supine
- B. Upright
- C. Left side-lying
- D. Right side-lying
Correct Answer: B
Rationale: During a paracentesis procedure for a client with abdominal ascites, the nurse should assist the client into an upright position. Placing the client upright allows the intestines to float posteriorly, reducing the risk of intestinal laceration during catheter insertion. Choices A, C, and D are incorrect because a supine, left side-lying, or right side-lying position would not provide the same benefit of intestinal mobility and protection during the procedure.