Case Study 4 (Shortness of Breath, Edema, and Decreased Urine Output) - Prioritization, Delegation, and Assignment
After discussing renal replacement therapies with the HCP and nurse, Ms. J is considering hemodialysis (HD). Which statement indicates that Ms. J needs additional teaching about HD? •"I will need surgery to create an access route for HD." •"I will be able to eat and drink what I want after I start dialysis." •"I will have a temporary dialysis catheter for a few months." •"I will be having dialysis three times every week."
•"I will be able to eat and drink what I want after I start dialysis." •Even after beginning HD, patients are still required to restrict fluid intake. In addition, patients on HD have nutritional restrictions (e.g., protein, potassium, phosphorus, sodium restrictions). All of the other patient statements indicate an appropriate understanding of HD.
While making rounds, the RN finds Ms. J in tears and sobbing. She states, "I just don't want to have to go back to dialysis 3 days a week!" What is the nurse's *best* response? •"Would you like me to call someone to come in and sit with you?" •"You can always get on the list for another kidney transplant." •"Tell me some more about how you are feeling." •"Let me call your health care provider to come in and speak with you."
•"Tell me some more about how you are feeling." •The RN should be supportive and nonjudgmental. Listening and encouraging the patient to verbalize her concerns (e.g., grief, feeling of failure) are essential at this time. Asking someone else to come in to talk with the patient is not responding to her concern. Suggesting that she can get on the transplant list again is not acknowledging Ms. J's grief for losing the transplanted kidney.
Ms. J is preparing for discharge. The RN is supervising a student nurse, who is teaching the patient about her discharge medications. For which statement by the student nurse will the RN intervene? •"Sevelamer prevents your body from absorbing phosphorus." •"Take your folic acid after dialysis on dialysis days." •"The docusate is to prevent constipation that may be caused by ferrous sulfate." •"You must take the epoetin alfa three times a week by mouth to treat anemia."
•"You must take the epoetin alfa three times a week by mouth to treat anemia." •Epoetin alfa is used to treat anemia and is given two to three times a week. However, it is given by either the IV or subcutaneous route. Most commonly epoetin alfa is given subcutaneously. All of the other statements about medications for patients with chronic kidney disease are accurate.
The RN team leader assigns the LPN/LVN to give Ms. J's 9:00 am oral medications. Which key instruction or action will be *most* important that the RN give the LPN/LVN regarding administering Ms. J's atenolol 50-mg tablet? •Give this drug with just a few swallows of water •Ask the patient if she has been taking a diuretic at home •Instruct the patient to use the bedside commode •Check the patient's heart rate and blood pressure
•Check the patient's heart rate and blood pressure •Atenolol is a beta-blocker drug with actions that slow the heart rate and decrease the blood pressure. HCPs often have blood pressure (BP) and heart rate (HR) guidelines (e.g., low BP and/or HR) for when to give and when to hold these drugs. The nurse should instruct the patient to call for help getting out of bed when the drug is newly prescribed or if the drug results in dizziness and syncope symptoms. The other instructions and actions may be included in the patient's care but will not affect the administration of atenolol.
Which patient admission tasks should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? *Select all that apply.* •Check vital signs every 4 hours •Record accurate intake and output •Place a saline lock in left forearm •Check oxygen saturation by pulse oximetry •Teach the patient the importance of keeping oxygen in place •Check and record the fingerstick blood glucose before lunch
•Check vital signs every 4 hours •Record accurate intake and output •Check oxygen saturation by pulse oximetry •Check and record the fingerstick blood glucose before lunch •Checking vital signs and recording intake and output fall within the scope of practice for any UAP. An experienced UAP will have been taught to use pulse oximetry to check oxygen saturation and to use a glucometer to check a patient's fingerstick blood glucose. However, in Canada, glucose monitoring is considered an advanced skill and would not be performed by UAP. Placing an IV line and teaching require additional education and training that are more within the scope of practice for a licensed nurse.
Ms. J states that she feels increasingly short of breath. The nurse team leader is supervising an LPN/LVN and a UAP. Which nursing care action for Ms. J should be *most* appropriately assigned to the LPN/LVN? •Checking for residual urine with the bedside bladder scanner •Planning restricted fluid amounts to be given with meals •Assessing breath sounds for increased bilateral crackles •Discussing renal replacement therapies with the patient
•Checking for residual urine with the bedside bladder scanner •Checking residual urine with a bedside bladder scanner is within the scope of practice of the LPN/LVN, who would remain under the supervision of the RN. Planning care and discussing options such as renal replacement therapies require additional education and training, which are within the scope of practice for the professional RN. Although in many acute care hospitals, LPN/LVNs auscultate breath sounds as a part of their observations, RNs follow up for overall assessment and synthesis of data. Because Ms. J is a potentially unstable patient with respiratory changes that may indicate worsening of her condition, the more appropriate person to assess her lung sounds would be the RN.
The team leader RN observes the UAP perform all of these actions for Ms. J. For which actions must the RN intervene? *Select all that apply.* •Assisting the patient to replace her oxygen nasal cannula •Checking vital signs after the patient has had something cold to drink •Ambulating with the patient to the bathroom and back •Increasing the patient's oxygen flow rate by nasal cannula from 2 to 4 L/min •Washing the patient's back, legs, and feet with warm water •Reminding Ms. J to perform prescribed incentive spirometry every hour while awake
•Checking vital signs after the patient has had something cold to drink •Increasing the patient's oxygen flow rate by nasal cannula from 2 to 4 L/min •Checking vital signs usually includes measuring oral body temperature. Because the patient just finished drinking fluids, an oral temperature measurement would be inaccurate at this time. If the fluids were cold, the temperature would be falsely low; if the fluids were hot, the temperature would be falsely high. Changing the oxygen flow rate without prescription or instruction is not acceptable practice. All of the other actions are appropriate and within the scope of practice of the UAP. A UAP's scope of practice includes reminding patients of content that has already been taught.
During admission assessment, Ms. J has all of these findings. For which finding should the nurse notify the HCP *immediately*? •Bilateral pitting ankle and calf edema rated + 2 •Crackles in both lower and middle lobes •Dry and peeling skin on both feet •Faint but palpable pedal and post-tibial pulses
•Crackles in both lower and middle lobes •All of these findings are important, but only the presence of crackles in both lungs is urgent because it signifies fluid-filled alveoli and interruption of adequate gas exchange and oxygenation, worsening of the patient's condition, and possibly pulmonary edema. The patient's peripheral edema is not new. The faint pulses are most likely caused by the presence of peripheral edema. The dry and peeling skin is a result of chronic diabetes and merits careful monitoring to prevent infection, but it is not immediately urgent.
The results of Ms. J's 24-hour urine collection reveals a creatinine clearance of 65 mL/min (1.09 mL/sec). How does the nurse *best* interpret this finding? •Creatinine clearance is lower than normal •Creatinine clearance is higher than normal •Creatinine clearance is within normal range •Creatinine clearance indicates adequate kidney function
•Creatinine clearance is lower than normal •The normal creatinine clearance is 107 to 139 mL/min for men (1.78-2.32 mL/sec) and 87 to 107 mL/min (1.45-1.78 mL/sec) for women tested with a 24-hour urine collection. A low result indicates that the kidneys are functioning at a lower than expected level. The patient has chronic kidney disease.
Assessment of Ms. J after dialysis reveals all of these findings. Which assessment finding necessitates *immediate* notification of the HCP? •Weight decrease of 4.5 lb (2 kg) •Systolic blood pressure decrease of 14 mm Hg •Decreased level of consciousness •Small blood spot near the center of the dressing
•Decreased level of consciousness •Changes in level of consciousness during or after HD can signal dialysis disequilibrium syndrome, a life-threatening situation that requires early recognition and treatment with anticonvulsants. This should be immediately reported to the HCP so that appropriate treatment can be prescribed. Decreases in weight and blood pressure are to be expected as a result of dialysis therapy. A small amount of drainage is common after HD.
The RN is precepting a new nurse orientating to the unit, who is providing care for Ms. J after her return from surgery to create a left forearm access for dialysis. Which action by the orienting nurse requires that the preceptor intervene? •Monitoring the patient's operative site dressing for evidence of bleeding •Obtaining a blood pressure reading by placing the cuff on the right arm •Drawing blood for laboratory studies from the temporary dialysis line •Administering acetaminophen with codeine PO for moderate postoperative pain
•Drawing blood for laboratory studies from the temporary dialysis line •Temporary dialysis lines are to be used only for HD. The preceptor nurse should stop the new nurse before the temporary HD system is interrupted. Breaking into the system increases the risk for complications such as infection. The blood pressure should always be assessed on the nondialysis arm. Postoperative patients should always be monitored for bleeding. Acetaminophen with codeine, when ordered by the HCP, is an appropriate analgesic for moderate to severe pain.
Which task associated with the patient's 24-hour urine collection is appropriate for the nurse to delegate to the UAP? •Instructing Ms. J to collect all urine with each voiding •Teaching Ms. J the purpose of collecting urine for 24 hours •Ensuring that all of Ms. J's urine collected for the test is kept on ice •Assessing Ms. J's urine for color, odor, and sediment
•Ensuring that all of Ms. J's urine collected for the test is kept on ice •Teaching, instructing, and assessing are all functions that require additional education and preparation appropriate to the scope of practice for professional nurses. Providing the patient with ice for the urine collection and reminding the patient to collect her urine fit the scope of practice of the UAP. Remember that the UAP can remind a patient about anything that has already been taught.
The RN is caring for Ms. J on the first day postoperatively after a kidney transplant. On assessment, her temperature is 100.4°F (38°C), her blood pressure is 168/92 mm Hg, and the patient tells the RN she has pain around the transplant site. What is the *best* interpretation of these findings? •Hyperacute rejection •Acute rejection •Chronic rejection •Transplant site infection
•Hyperacute rejection •Hyperacute rejection occurs within 48 hours after transplant surgery. Increased temperature, increased blood pressure, and pain at the transplant site are manifestations.
Which risk factors in Ms. J's history indicate increased risk for chronic kidney disease (CKD)? *Select all that apply.* •GERD •Hypertension •Four pregnancies •Type 2 diabetes •Coronary artery disease (CAD) •Cataracts
•Hypertension •Type 2 diabetes •Coronary artery disease (CAD) •Major risk factors for CKD include hypertension and diabetes. CAD has a related pathophysiology to hypertension. Pregnancy, cataracts, and GERD are not risk factors for CKD.
What intervention is required at this time? •Increased doses of immunosuppressive drugs •IV antibiotics •Conservative management including dialysis •Immediate removal of the transplanted kidney
•Immediate removal of the transplanted kidney •The treatment for hyperacute rejection is immediate removal of the transplanted kidney and return to dialysis until another kidney becomes available. Increased doses of immunosuppressant drugs are used to treat acute rejection, conservative management is used for chronic rejection, and IV antibiotics are administered for infections.
Ms. J's care plan includes the nursing concern, excess fluid volume. What interventions are appropriate for this nursing concern? *Select all that apply.* •Measure weight daily •Monitor daily intake and output •Restrict sodium intake with meals •Restrict fluid to 1500 mL plus urine output •Assess for crackles in the lungs every shift •Check for peripheral edema and note any increase
•Measure weight daily •Monitor daily intake and output •Restrict sodium intake with meals •Assess for crackles in the lungs every shift •Check for peripheral edema and note any increase •The usual fluid restriction for patients with chronic kidney failure is 500 to 700 mL plus urine output. All of the other actions are appropriate for a patient with fluid overload. Remember that it is essential for the nurse to compare findings with previous shifts and days to determine if symptoms are worsening.
Six months later, Ms. J is readmitted to the unit. She has just returned from HD. Which nursing care action should the nurse delegate to the UAP? •Measuring vital signs and postdialysis weight •Assessing the HD access site for bruit and thrill •Checking the access site dressing for bleeding •Instructing the patient to request assistance getting out of bed
•Measuring vital signs and postdialysis weight •Measuring vital signs and weighing the patient are within the education and scope of practice of the UAP. The UAP could remind the patient to request assistance when getting out of bed after the RN has instructed to patient to do so. Assessing the HD access site for bleeding, bruit, and thrill require additional education and skill and are appropriately performed by a licensed nurse.
The RN is delegating and assigning care for Ms. J related to her type 2 diabetes. Which action by the RN indicates that the team leader needs to intervene? •RN delegates fingerstick glucose check to newly hired UAP •RN assigns administering morning dose of metformin to the LPN/LVN •RN refers the patient to a dietitian for education about a diabetic diet •RN assesses condition of patient's feet daily
•RN delegates fingerstick glucose check to newly hired UAP •The newly hired UAP would need to be taught how to use a glucometer and perform a fingerstick before having this task delegated to him or her. All of the other care tasks are appropriate to the staff members.
The RN reviews Ms. J's laboratory results. Which laboratory finding is of *most* concern? •Serum potassium level of 7.1 mEq/L (7.1 mmol/L) •Serum creatinine level of 7.3 mg/dL (645 μmol/L) •Blood urea nitrogen level of 180 mg/dL (64.3 mmol/L) •Serum calcium level of 7.8 mg/dL (1.95 mmol/L)
•Serum potassium level of 7.1 mEq/L (7.1 mmol/L) •A patient with a serum potassium level of 7 to 8 mEq/L (7-8 mmol/L) or higher is at risk for electrocardiographic changes and fatal dysrhythmias. The HCP should be notified immediately about this potassium level. Although the serum creatinine and blood urea nitrogen levels are high, these levels are commonly reached before patients experience symptoms of chronic kidney disease (CKD). The serum calcium level is low but not life threatening. Keep in mind that there is an inverse relationship between calcium and phosphorus, so when calcium is low, expect phosphorus to be high.
Which medication should the nurse be prepared to administer to lower the patient's potassium level? •Furosemide 40 mg IV push •Epoetin alfa 300 units/kg subcutaneously •Calcium 1 tablet PO •Sodium polystyrene sulfonate 15 g PO
•Sodium polystyrene sulfonate 15 g PO •Sodium polystyrene sulfonate removes potassium from the body by exchanging sodium for potassium in the large intestine. Diuretics such as furosemide generally do not work well in chronic kidney failure. The patient may need a calcium supplement and subcutaneous epoetin alfa; however, these drugs do nothing to decrease potassium levels.
