Exam 1 Case Study ?s

The next week, the patient's urine output increases to 3500 mL over 24 hours. The BUN and creatinine remain elevated and the GFR is now 48 mL/minute. Which collaborative and nursing actions will the nurse plan to implement during the diuretic phase of acute kidney injury?

*Important points:* •During the diuretic phase of acute kidney injury, the kidneys are unable to concentrate urine and urine output increases to as much as 5 L/day. •The patient may develop dehydration and hypovolemia, with potential shock and recurrent kidney injury. •The kidney continues to be unable to perform other functions, such as remove metabolic wastes, control acid-base balance, and maintain normal electrolyte levels. •The patient may develop hyponatremia and hypokalemia during this phase. •Nursing and collaborative interventions include: 1. Careful assessment for manifestations of dehydration and hypovolemia: vital sign changes, such as hypotension and tachycardia, poor pulse quality, flat neck veins, dry oral mucosa, poor skin turgor, and changes in orientation and alertness. 2. Assessment for electrolyte disturbances, such as hyponatremia or hypokalemia caused by diuresis. 3. Infusion of fluids (based on the patient's I & O and fluid balance) and monitoring for signs of fluid excess, such as hypotension or hypertension, tachycardia, increased respiratory rate and dyspnea, crackles in the lungs, pericardial and pleural friction rubs, peripheral edema, and increases in daily weights.

Initial laboratory results: *CBC* White blood cells (WBCs): 9500/µL (9.5 x 109/L) Hemoglobin: 15 g/dL (150 g/L) Hematocrit: 48% (0.48) *Blood Chemistry* Glucose: 136 mg/dL (7.6 mmol/L) Albumin 3.4 mg/dL (34 g/L) Blood urea nitrogen (BUN): 44 mg/dL (15.7 mmol/L) Creatinine: 1.9 mg/dL (168 µmol/L) Sodium 149 mEq/L (149 mmol/L) Potassium 5 mEq/L (5 mmol/L) Chloride 112 mEq/L (112 mmol/L) *Lactate Level* 20 mcg/dL (2.2 mmol/L)

*Instructor: Suggest review of patient's laboratory results and review of normal ranges, then move on to the next slide to discuss which results are of most concern for this patient.* Normal values: WBCs: 4,000 to 11,000 µL (4.0 to 11.0 × 109/L). Hemoglobin: For men, 13.2 to 17.3 g/dL (132 to 173 g/L). For women, 11.7 to 15.5 g/dL (117 to 155 g/L) Hematocrit: For men, 39% to 50% (0.39 to 0.50). For women, 35% to 47% (0.35 to 0.47) Glucose: (fasting): 70 to 99 mg/dL (3.9 to 5.5 mmol/L) Albumin: 3.5 to 5.0 g/dL (35 to 50 g/L) BUN: 6 to 20 mg/dL (2.1 to 7.1 mmol/L) Creatinine: 0.6 to 1.3 mg/dL (53 to 115 µmol/L) Sodium: 135 to 145 mEq/L (135 to 145 mmol/L) Potassium: 3.5 to 5.0 mEq/L (3.5 to 4.5 mmol/L) Chloride: 96 to 106 mEq/L (96 to 106 mmol/L) Lactate: 6.3 to 22.5 mg/dL (0.7 to 2.5 mmol/L)

Which task related to diagnostic testing of chronic pancreatitis can be delegated to the unlicensed assistive personnel (UAP)? A.Reinforcing nurse's explanation of NPO before endoscopic retrograde cholangiopancreatography B.Transporting the patient's blood sample to the laboratory for a Helicobacter pylori antibody test C.Obtaining a stool specimen and observing for stool characteristics or steatorrhea D.Assessing for metallic prosthesis or other metal objects prior to magnetic resonance imaging

ANS: A Focus: Delegation The UAP can reinforce the nurse's instructions, but the nurse is responsible for explaining NPO status to the patient and ensuring that the NPO order is communicated to all team members. An H. pylori antibody test is done for ulcers, gastritis, or esophagitis. The UAP could collect a stool specimen but is not expected to observe for steatorrhea or other stool characteristics. The nurse should assess for the presence of metallic objects or prosthesis and explain to the patient why metal must be removed. The nurse can then delegate removal of metallic objects, such as jewelry or hairclips to the UAP.

The patient tells you that her room is too hot and she is sweating too much. To promote comfort, which instruction would you give the UAP? A.Reduce the room temperature. B.Change the bed linen every day. C.Assist the patient to take a warm shower. D.Provide room temperature water.

ANS: A Focus: Delegation, Prioritization Decreasing the room temperature will decrease the discomforts of heat intolerance. The UAP may need to change linens several times a day; showers should be cool, and drinking water should be iced. All of these will help decrease patient discomfort related to heat intolerance and diaphoresis.

Which assessment finding for this patient is most important to report to the HCP? A.Heart rate 46 and prolonged QRS duration B.Crackles at lung bases and peripheral edema C.Confusion and 1+ deep tendon reflexes D.Nausea and abdominal distention

ANS: A Focus: Prioritization The bradycardia and QRS prolongation are caused by the markedly elevated serum potassium level; rapid action is needed to prevent cardiac arrest. The other findings are also associated with acute kidney injury and poor renal function but are not life threatening.

Which outcome statement best indicates that the pancreatic enzyme therapy is effective? A.Patient reports that stools are less frequent and stool analysis shows decreased fat content. B.Patient reports decreased subjective hunger and thirst and blood glucose level is normal. C.Patient reports abdominal pain is less frequent and serum bilirubin is decreased. D.Patient reports fewer episodes of heartburn and acid-stomach and electrolytes are normal.

ANS: A Focus: Prioritization The purpose of pancreatic enzyme therapy is to aid in the digestion of fats. Efficacy is measured by reduction of fat excretion in the stool and decreased frequency of stool. Diabetes mellitus can develop secondary to loss of pancreatic endocrine function; therapy includes: insulin or oral hypoglycemic and diet. Opioids are given for acute pain and non-opioids are used for the chronic pain associated with pancreatitis. Bilirubin can be elevated if the bile duct is obstructed. Acid suppressants may be given to protect the enzymes and thereby enhance effectiveness. Electrolytes should be normal unless the patient is dehydrated.

A patient with a presumptive diagnosis of chronic pancreatitis should also be assessed and questioned about which set of symptoms? A.Polyphagia, polydipsia, and polyuria B.Palpitations, dizziness, and cool extremities C.Eructation, flatulence, and bloating D.Nocturia, proteinuria, and uremic fetor

ANS: A Focus: Prioritization While a complete history and review of symptoms must always be performed, loss of pancreatic endocrine function causes development of diabetes mellitus in patients with chronic pancreatic insufficiency. Polyphagia, polydipsia, and polyuria are commonly associated with diabetes mellitus. Palpitations, dizziness, and cool extremities are associated with decreased cardiac output, such as in left-sided heart failure. Eructation, flatulence, and bloating are symptoms of gastroesophageal reflux disease. Nocturia, proteinuria, and uremic fetor are symptoms of kidney failure.

Which tasks could the nurse assign to the licensed practical nurse/licensed vocational nurse (LPN/LVN) working with you to provide care for this patient? *(Select all that apply.)* A.Checking vital signs every 4 hours B.Weighing the patient every day after dialysate drain C.Administering oral analgesics as needed D.Measuring the abdominal circumference every shift E.Creating a nursing care plan for the patient F.Recording the shift physical assessment

ANS: A, B, C, D Focus: Assignment Vital signs, weighing patients, administering oral medications, and measuring abdominal circumference are all within the scope of practice for the LPN/LVN. A unlicensed assistive personnel (UAP) could also perform A, B, and D. Creating nursing care plans and assessment are appropriate to the RN's scope of practice. In some states, an LPN/LVN can administer IV drugs and record assessments with additional training. Also in some facilities, if the patient's illness is chronic and stable, the LPN/LVN may be permitted to perform the assessment. In this case, the RN should perform the assessment because it requires formative evaluation of response to therapy.

The nurse is preparing a nursing care plan for the patient with focused areas on nutrition, hyperthermia, and fatigue. Which interventions would be appropriate to delegate to the unlicensed assistive personnel (UAP) working with you? *(Select all that apply.)* A.Checking and reporting the patient's vital signs every 4 hours B.Assisting the patient to the bathroom as needed C.Assessing for signs and symptoms of infection D.Recording intake from every meal E.Administering propylthiouracil (PTU) 50 mg every 8 hour F.Ensuring the patient always has fresh ice water at the bedside

ANS: A, B, D, F Focus: Delegation Checking and reporting vital signs is within the scope of practice for UAPs (be sure to instruct the UAP to report any temperature increase immediately and assess cardiac status if this occurs); patient care assistance, recording intake, and providing ice water are within the scope of practice for UAPs. The administration of medications is appropriate to the RN or the licensed practical nurse/licensed vocational nurse (LPN/LVN) scope of practice, and assessing for manifestations of infection is within the RN scope of practice.

To prevent poor dialysate flow, which key points would the nurse teach this patient about PD? *(Select all that apply.)* A. Be sure to consume a high fiber diet. B. Remember to take your daily stool softener. C. Warm the dialysate bags in your microwave oven. D. An enema before PD may be helpful. E. Expect the PD outflow to be cloudy. F. Check for kinked or clamped connection tubing.

ANS: A, B, D, F Focus: Prioritization The most common cause of poor dialysate flow is related to constipation. To prevent constipation, a bowel preparation is usually prescribed before starting PD. An enema before PD may help prevent poor dialysate flow. Other strategies to prevent constipation include stool softeners and high fiber diets. Additional causes of poor dialysate flow include kinked or clamped tubing, patient position, fibrin clot formation, and catheter displacement.

Which are safety precautions for a patient receiving an unsealed radioactive isotope? *(Select all that apply.)* A. Use a toilet not used by others for 2 weeks. B. Flush the toilet six times after each use. C. Wash clothes separately from others in the household. D. Avoid close contact with pregnant women, infants, and small children. E. Use cotton handkerchiefs to blow your nose. F. Use disposable utensils, plates, and cups.

ANS: A, C, D, F Focus: Prioritization Toilets should be flushed three times after each use and disposable tissues should be used. The tissues should be flushed down the toilet or kept in a plastic bag to be turned in to the radiation department of the hospital for disposal. The other statements about safety precautions for a patient receiving an unsealed radioactive isotope are accurate.

The health care provider prescribes IV fluids and broad spectrum antibiotics for the patient after confirming the diagnosis of peritonitis. Which actions associated with the IV therapy should be delegated to the UAP? *(Select all that apply.)* A.Recording daily intake and output B.Placing a nasogastric (NG) tube to decompress the stomach C.Checking the placement of the nasal cannula for oxygen during every patient contact D.Administering analgesics for pain E.Assessing lung sounds each shift F.Assisting the patient out of bed into the chair

ANS: A, C, F Focus: Delegation Recording I&O, checking the oxygen cannula placement, and assisting patients to get out of bed are all within the scope of practice for the UAP. Placing an NG tube, administering medications, and assessing lung sounds are more appropriate to the RN's scope of practice. An LPN/LVN could also administer oral analgesics.

What lab values would support the diagnosis of hyperthyroidism? *(Select all that apply.)* A.Increased T3 and T4 B.Decreased T3 and T4 C.Increased thyroid-stimulating hormone (TSH) D.Decreased TSH E.Thyroid antibodies—high titer F.Thyroid scan—increased uptake of radioactive iodine (RAI)

ANS: A, D, E, F Focus: Prioritization Thyroid hormones T3 (triiodothyronine) and T4 (thyroxine) are increased; TSH is low in hyperthyroidism caused by Graves disease (most common cause); high titer of antithyroglobulin occurs with hyperthyroidism; a thyroid scan demonstrates an increased uptake of RAI.

The patient is admitted with diagnoses of dehydration and possible acute kidney injury, and with instructions from the HCP to "continue patient's usual home medications." Which medications will the nurse need to discuss with the HCP prior to administering? (Select all that apply.) A.Lisinopril 10 mg/day B.Citalopram 10 mg/day C.Gabapentin 800 mg TID D.Hydrochlorothiazide 25 mg/day E.Acetaminophen 650 mg every 8 hours F.Ibuprofen 200 mg every 6 hours PRN

ANS: A, D, F Focus: Prioritization Since the patient has volume depletion, it will not be appropriate to administer a diuretic. Angiotensin converting enzyme (ACE) inhibitors such as lisinopril will lower BP further in this hypotensive patient. In addition, hyperkalemia is an adverse effect of ACE inhibitors and acute kidney damage also increases risk for elevated serum potassium. Nonsteroidal anti-inflammatory drugs (NSAIDS) are nephrotoxic and should not be administered at this time. The other medications are safe to administer.

The patient is treated for hyperkalemia and CCRT is initiated. Which actions will the nurse delegate to the unlicensed assistive personnel (UAP) who are helping with the care for this patient? *(Select all that apply.)* A.Replace the electrocardiogram (ECG) electrodes. B.Check the dialysis tubing for clot formation. C.Monitor for changes in orientation. D.Inspect the oral mucosa for dryness or cracking. E.Obtain a BP and urine output hourly.

ANS: A, E Focus: Delegation Since placing ECG electrodes, obtaining vital signs, and measuring urine output are skills that are frequently done in daily care and require little modification between patients, these actions are appropriate to delegate to the UAP. Monitoring dialysis equipment and obtaining physical assessment data require nursing judgment and critical thinking and should be done by the RN.

The patient's outflow (effluent) is cloudy as reported by the LPN/LVN. What would the nurse instruct the LPN/LVN to do at this time? A.Empty the outflow bag into the sink. B.Send a sample of effluent to the laboratory. C.Tell the patient to drink lots of fluids. D.Change the dressing around the patient's dialysis catheter.

ANS: B Focus: Assignment, prioritization Cloudy or opaque effluent is the earliest sign of peritonitis and is an indication of infection. A sample should be collected and sent to the lab for culture and sensitivity, gram stain, and cell count to identify the infecting organism. The outflow bag will need to be emptied after the sample is sent. The LPN/LVN should change the dressing if needed, and encourage the patient to drink adequate fluids, but these are not specific to the patient's cloudy outflow.

Which laboratory results are most important for the nurse to communicate to the HCP? A.Electrolyte levels B.BUN and creatinine level C.Lactate and glucose levels D.WBC count and hematocrit

ANS: B Focus: Prioritization BUN and creatinine are elevated, indicating likely acute kidney injury caused by the patient's volume depletion. The electrolyte levels are in the high-normal to slightly elevated range, but do not require any immediate action aside from fluid infusion. Lactate is at the high-normal level and indicates physiological stress, but not at the level that would suggest sepsis as a cause for the hypotension and tachycardia. Mild glucose elevation is expected in ill patients because of the stress response. WBC count and hematocrit are normal. The high-normal hemoglobin and hematocrit suggest possible hemoconcentration caused by volume depletion.

Which patient statement most indicates a need for follow-up by the nurse about CAPD? A."I am supposed to use sterile technique when connecting or disconnecting the catheter tubing." B."I usually perform my dialysis exchanges in the dining room on the table." C."I run the dialysate in quickly over 10 to 20 minutes." D."I will be able to travel on vacation with my PD."

ANS: B Focus: Prioritization CAPD must be performed by the patient using sterile technique; performing exchanges on the dining room table may expose the patient to organisms and lead to peritonitis. It would be essential that the nurse clarify how the patient will accomplish the exchanges. Use of sterile technique is essential to prevent infection. The dialysate is infused quickly over 10 to 20 minutes, and patients can travel with PD.

The HCP prescribes these actions. Which will the nurse implement first? A.Decrease IV fluids to 50 mL/hour. B.Administer calcium chloride 1000 mg IV. C.Give sodium polystyrene sulfonate 15 g. D.Notify the dialysis department to prepare for continuous renal replacement therapy (CCRT).

ANS: B Focus: Prioritization Calcium chloride administration will rapidly shift potassium from the extracellular to the intracellular space and correct the patient's bradycardia and QRS widening. This effect only lasts about 30 to 60 minutes, so the nurse will also need to administer sodium polystyrene sulfonate, which will work over the next few hours to bind potassium and eliminate it through the gastrointestinal tract. This will lower the total body potassium level. The patient's laboratory and assessment information indicates that decreasing fluid intake and hemodialysis or CCRT are also appropriate, but the nurse's first action should be to correct potentially fatal dysrhythmias caused by the hyperkalemia.

The nurse is interviewing a patient who will undergo diagnostic testing to confirm a diagnosis of chronic pancreatitis. Which early symptom is the most likely reason for the patient to seek treatment? A.Abdominal ascites B.Burning or gnawing abdominal pain C.Steatorrhea: clay-colored stools D.Left upper quadrant mass

ANS: B Focus: Prioritization Relentless abdominal pain that is described as a burning or gnawing sensation is the most likely reason for the patient to seek treatment and the most likely clinical finding. Steatorrhea and ascites occur as the condition progresses. Left upper quadrant pain is present if a pseudocyst or abscess occurs.

The patient is a 29-year-old woman who comes to the emergency department with a history of diaphoresis, unplanned weight loss despite increased appetite, and palpitations. Assessment reveals a wide-eyed look, a small thyroid mass, and vital signs including blood pressure (BP) 148/92, heart rate (HR) 104 beats/minute, temperature 98.4°F (36.9°C), and respiratory rate (RR) 24 breaths/minute. Her history includes decreased menstrual flow, increased fatigue, and weakness. *Which nursing concept will the nurse use to interpret data and plan care for this patient?* A.Safety B.Hormonal regulation C.Perfusion D.Cellular regulation

ANS: B Focus: Prioritization The thyroid gland produces thyroid hormones (T3 and T4) which are important in control of metabolism. Both hormones increase metabolism. Weight loss, diaphoresis (heat intolerance), palpitations, exophthalmos (wide-eyed, startled look), presence of goiter (thyroid mass), decreased menstrual, as well and increased BP, HR, and RR are all classic manifestations of hyperthyroidism. A patient with hypothyroidism would present with the opposite picture such as weight gain, cold intolerance, bradycardia, hypotension, and decreased respiratory function.

A 60-year-old who has had vomiting and diarrhea for the last 2 days arrives in the emergency department. Vital signs are: Temperature: 100.1°F (37.8°C); Pulse: 112; Respirations: 24; Blood Pressure (BP): 88/60. *Which action prescribed by the health care provider (HCP) will the nurse implement first?* A.Give metoclopramide10 mg IV. B.Infuse 1 L of normal saline over 60 minutes. C.Administer acetaminophen 650 mg rectal suppository. D.Draw blood for complete blood count (CBC), blood chemistries, and lactate level.

ANS: B Focus: Prioritization This patient's history of vomiting and diarrhea are risk factors for volume deletion and hypovolemia, the most common causes of acute kidney injury. The BP and pulse indicate likely hypovolemic shock. Rapid isotonic fluid replacement is needed to improve perfusion and avoid organ damage, including acute prerenal kidney injury. The other actions are also necessary, but replacement of volume loss and maintenance of perfusion to vital organs is the most immediate need for this patient.

What should the nurse tell the patient about how to use the pancreatic enzymes at home? *(Select all that apply.)* A.If you have trouble swallowing pills, mix the enzyme in a soft food like low-fat cottage cheese. B.Capsules should not be chewed or crushed. C.Take medication with all meals and snacks. D.Do not hold the capsule or capsule contents for prolonged times in the mouth. E.Drink sufficient water to swallow the medication completely. F.Check blood glucose before meals and adjust the dose of enzyme as needed.

ANS: B, C, D, E Focus: Prioritization Capsules should not be chewed or crushed. The capsules contents can irritate oral mucosa, so they should be taken with plenty of water and not held in the mouth. Enzymes should be taken with all meals and snacks. Nurse or dietician should review diet management with patient. Enzyme can be mixed with soft acidic foods such as applesauce if needed, but not with dairy products because the higher pH could destroy enzyme activity. The patient may be checking blood glucose, because of concurrent development of diabetes mellitus, but the enzymes are not adjusted for glucose levels.

Which tasks related to the care of the patient with chronic pancreatitis should be assigned to the licensed practical nurse/licensed vocational nurse (LPN/LVN)? *(Select all that apply.)* A.Weigh daily at the same time of day and record the findings. B.Administer pancreatic enzymes with meals as ordered. C.Evaluate the effectiveness of the pancreatic enzyme therapy. D.Assist to eat a food tray with high-carbohydrate and low-fat foods. E.Observe for and report respiratory complications such as dyspnea or orthopnea. F.Assess for pain relief after trying nonpharmacologic strategies.

ANS: B, E, F Focus: Assignment LPN/LVN can administer the medications and is expected to recognize and immediately report unexpected complications, such as dyspnea or orthopnea. LPN/LVN performs routine assessment (e.g., pain) on stable patients. The RN is responsible for the initial assessment of all patients and the assessment of unstable patients and for evaluating the therapeutic outcomes. The UAP should be assigned to weigh the patient and assist with the dietary tray.

The health care provider informs the nurse that the patient has a fibrin clot formation on the PD catheter. What is the nurse's best action at this time? A. Clamp the catheter tubing B. Reposition the catheter C. Milk the catheter tubing D. Reposition the patient

ANS: C Focus: Prioritization Fibrin clot formation can occur after PD catheter placement. Milking the tubing can dislodge the clot and improve dialysate flow. An x-ray may be ordered to verify the position of the PD catheter and if displacement has occurred, the health care provider will reposition the PD catheter.

The patient has edema of the feet, hands, and legs. Based on this assessment finding, which laboratory result will be the most important for the nurse to monitor? A.Blood glucose B.Triglycerides C.Albumin level D.Stool analysis

ANS: C Focus: Prioritization In chronic pancreatitis, all of these laboratory results are likely to be abnormal; however protein malabsorption results in decreased albumin level which can manifest as edema in the extremities, because of decreased oncotic pressure. Blood glucose will be elevated when pancreatic endocrine function is insufficient, because diabetes mellitus can develop. Elevated triglycerides can contribute to the development of pancreatitis. In severe chronic pancreatitis, stool analysis will reveal a high fat content.

The HCP prescribes these diagnostic tests. Which test will be most important for the nurse to question? A.Bladder scan B.Bilateral renal ultrasonography C.Abdominal computed tomography (CT) with and without contrast D.X-ray of the kidneys, ureters, and bladder (KUB)

ANS: C Focus: Prioritization In patients who are hypovolemic or those who have pre-existing chronic kidney disease, use of contrast for diagnostic testing is associated with increased risk for acute kidney injury, since the contrast acts as an osmotic diuretic and can further decrease volume. Although the data about this patient suggest a prerenal etiology for the elevation in creatinine and BUN, bladder scans and renal ultrasonography are noninvasive and are appropriate diagnostic tests if there is any reason to suspect obstructive issues such as prostatic hypertrophy or nephrolithiasis as causes of the decreased renal function. KUB is also noninvasive and may be used to screen for abdominal masses, kidney stones, or enlarged kidneys that may be contributing to the elevated creatinine and BUN.

The UAP reports that the patient's oral temperature with 8 AM vital signs is 99.8°F (37.7°C). What is the nurse's priority action at this time? A.Administer two tablets of acetaminophen. B.Lower the patient's room temperature. C.Notify the health care provider. D.Instruct the patient to rest quietly.

ANS: C Focus: Prioritization Increases in the temperature of a patient with hyperthyroidism may indicate the onset of thyroid storm, a life-threatening event that occurs with uncontrolled hyperthyroidism, characterized by high fever and hypertension. You should immediately report a temperature increase of even one degree. If a UAP is checking vital signs, be sure to instruct them to report the patient's temperature as soon as it is obtained. If the temperature is elevated, immediately assess the patient's cardiovascular status and if the patient is on a cardiac monitor, check for dysrhythmias.

The patient is a 54-year-old man with chronic kidney disease (CKD) who has performed continuous ambulatory peritoneal dialysis (CAPD) QID, 7 days a week for the past 6 months. During the nurse's initial assessment, the patient reports abdominal pain, nausea with vomiting, and constipation. Assessment findings include diminished bowel sounds, rebound tenderness, and abdominal distention. Vital signs include heart rate: 112/minutes, and temperature: 101.8°F (38.8°C). *What major complication does the nurse suspect?* A.Hemorrhage B.Fibrin clot formation C.Peritonitis D.Exit site infection

ANS: C Focus: Prioritization Peritonitis is the major complication of peritoneal dialysis (PD). The cardinal signs of peritonitis are abdominal pain and tenderness. Other manifestations include nausea and vomiting, constipation, decreased bowel sounds, rebound tenderness, abdominal distention, tachycardia, and high fever.

The nurse notes that the patient has poor dialysate flow. Which question will the nurse ask to determine the cause of this complication? A."How much fluid did you consume today?" B."Do you have a regular exercise regimen?" C."When was your last bowel movement?" D."Which drugs have been prescribed for you?"

ANS: C Focus: Prioritization The most common cause of poor dialysate flow is related to constipation. To prevent constipation, a bowel preparation is usually prescribed before starting PD.

Two days later, the nurse reviews the results of the day's diagnostic testing. Which result is most important to report to the HCP? A.BUN 76 mg/dL (27 mmol/L) B.Hematocrit 33% (0.33) C.Serum potassium 7.2 mEq/L (7.2 mmol/L) D.Glomerular filtration rate (GFR) 25 mL/minute

ANS: C Focus: Prioritization The serum potassium level indicates severe hyperkalemia, which may result in bradycardia and cardiac arrest unless it is corrected quickly. The elevated BUN and decreased GFR indicate that the patient has developed acute kidney injury and will also need to be reported but are not immediately life threatening. The patient's anemia may be chronic, or caused by hemodilution or by decreased erythropoietin production by the injured kidneys, but does not need to be addressed immediately.

The health care provider orders RAI therapy for the patient. What priority question would the nurse be sure to ask the patient before this therapy is given? A."Have you noticed any increased tearing or a bloodshot appearance of your eyes?" B."Do you have periods of amenorrhea or decreased menstrual flow?" C."How many bowel movements do you have in a typical day?" D."Are you pregnant or trying to become pregnant?"

ANS: D Focus: Prioritization RAI therapy is not used with pregnant women because it crosses the placenta and can damage the fetal thyroid gland. It is important to ask all of these questions, but the question about pregnancy is a priority.

The patient with hyperthyroidism is scheduled for a subtotal thyroidectomy. What are care priorities preoperatively and postoperatively?

Important points: *Preoperative* 1.Treat with thyroid drugs for near normal thyroid function. 2.Control hypertension, tachycardia, and dysrhythmia. 3.Teach the patient cough and deep breathing exercises. 4.Teach the need to support the head and neck when coughing postoperatively. 5.Teach the patient about postoperative care. *Postoperative* 1.Monitor for complications: bleeding, hypocalcemia, tetany, difficulty breathing, laryngeal nerve damage, and thyroid storm. 2.Assess the patient's level of discomfort. 3.Position to support the head and neck (pillows, sandbags)—avoid neck extension. 4.Give medications as ordered. 5.Humidify oxygen/air. 6.Assist with cough and deep breathing.

The patient tells you that he is quite confident in his skills for performing CAPD, and does not need a back-up support person who also knows how to perform this procedure. How would you discuss this with him?

Important points: •Sick days when the patient may not be able to perform his own CAPD •Praise for his skills •Need for sterile technique

Which information is key to include when teaching the patient about RAI therapy? *(Select all that apply.)* A. RAI is performed on an inpatient basis. B. RAI may be administered orally. C. Complete symptom relief may take 6 to 8 weeks. D. Some patients may need a second or third dose of RAI. E. The radiation dose is usually eliminated within a week. F. Some patients require lifelong therapy with thyroid hormone replacement.

NS: B, C, D, F Focus: Prioritization RAI therapy is usually performed on an outpatient basis. The radiation dose is usually eliminated within a month. All of the other statements about RAI are accurate and should be included in a teaching plan for a patient who is to receive RAI therapy.