Nokea
The nurse is preparing to admit a client with chronic kidney disease and congestive heart failure. Which assessment would most effectively determine the client's fluid balance?
- A. Daily weight
- B. Intake and output measurement
- C. Urine specific gravity
- D. Serum sodium level
Correct Answer: A
Rationale: Daily weight is the most effective way to assess fluid balance, reflecting changes in fluid status.
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The nurse is assessing a client with an acute kidney injury (AKI). Which of the following findings would support a diagnosis of AKI?
- A. hypernatremia
- B. metabolic alkalosis
- C. oliguria
- D. hypokalemia
Correct Answer: C
Rationale: Oliguria is a hallmark of AKI due to reduced kidney perfusion and filtration.
The nurse is providing education to a group of nursing students regarding the causes of hypercalcemia. Which of the following information should be included? Select all that apply.
- A. hypoparathyroidism.
- B. thiazide diuretics.
- C. malignancy.
- D. end-stage kidney disease.
- E. Crohn's disease.
Correct Answer: B,C,D
Rationale: Thiazide diuretics, malignancy, and end-stage kidney disease cause hypercalcemia by increasing calcium retention or release.
The oncoming nurse learns that her new patient is suffering from Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion. Which of the following nursing actions is the most important?
- A. Assess the patient's mental status
- B. Provide oral hygiene
- C. Keep accurate intake and output measurements
- D. Reduce stress and discomfort
Correct Answer: A
Rationale: SIADH causes hyponatremia, which can lead to neurological changes, making mental status assessment critical.
The following scenario applies to the next 6 items.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 2 of 6
History and Physical
A 57-year-old male client with stage three small cell lung cancer. The client had suddenly become disoriented and did not recognize his family members and relatives. He reports severe lower extremity weakness and has had three episodes of diarrhea in the past four hours. The client is undergoing 6 cycles of chemotherapy with cisplatin and etoposide. He is currently taking a 14-day course of 15 mg of prednisone. He is on his third day of steroid treatment. He has a medical history of dyslipidemia and advanced chronic obstructive pulmonary disease.
Nurses' Notes
0759: Client is completely disoriented and required maximum assistance to the stretcher because of unsteady gait. Lung sounds clear bilaterally. Alopecia noted. Skin is warm and dry and normal for ethnicity. Peripheral pulses 2+. No skin tenting. Hyperactive bowel sounds in all quadrants. 20-gauge peripheral vascular access device placed in the left antecubital space. T 97.8° F (36.6° C) P 88 RR 21 BP 123/68 Pulse oximetry reading 91% on room air.
Laboratory Results
• Hemoglobin 14 g/dL [14-18 g/dL (140–180 g/L)]
• Hematocrit 42% (0.42) [42-52% (0.42-0.52)]
• White Blood Cell 11,000 mm3 [5-10 mm3]
• Platelet Count 140,000 mm3 [150-400 mm3 (150–400 × 109/L)]
• Glucose 139 mg/dL (7.72 mmol/L) [70–110 mg/dL (4-6 mmol/L)]
• Sodium 116 mEq/L [136–145 mEq/L (mmol/L)]
• Potassium 3.3 mEq/L [3.5–5.0 mEq/L (mmol/L)]
• Creatinine 0.7 mg/dL (61.88 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Blood Urea Nitrogen 8 mg/dL (2.86 mmol/L) [10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum Osmolality 277 mOsm/kg [285-295 mOsm/kg (285–295 mmol/kg)]
The nurse focuses on the client's serum sodium level and recognizes which conditions may cause hyponatremia or hypernatremia. For each condition below, click to specify if it causes hyponatremia or hypernatremia.
- A. syndrome of inappropriate antidiuretic hormone (SIADH)
- B. diabetes insipidus (DI)
- C. adrenal insufficiency
- D. Cushing's syndrome
Correct Answer: A: Hyponatremia, B: Hypernatremia, C: Hyponatremia, D: Hypernatremia
Rationale: SIADH and adrenal insufficiency cause hyponatremia via water retention or sodium loss. DI and Cushing's syndrome cause hypernatremia via water loss or sodium retention.
The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PHCP)?
- A. WBC 19,000 mm3 [5,000-10,000 mm3]
- B. Hemoglobin 9 g/dL [Male: 14-18 g/dL (140-180 g/L) Female: 12-16 g/dL (120-160 g/L)]
- C. Calcium 8.6 mg/dL [9.0-10.5 mg/dL]
- D. Serum pH 7.33 [7.35-7.45]
Correct Answer: A
Rationale: Elevated WBC (19,000 mm3) suggests infection, a serious complication in peritoneal dialysis.