Critical Care Exam 2 (renal, heme, misc.)

End stage renal disease

5th stage of CKD GFR less than 15 treatment is kidney transplant or lifelong dialysis

A male patient presents in the ER with petechia, purpura, and shortness of breath. The patient is given fresh frozen plasma. Upon discharge what teaching intervention will be included in the plan of care? A. brush teeth with a soft bristle brush B. Use a razor to shave C. Patient will be able to rejoin wrestling team D. Patient should monitor BP q2h

? p.471

Hemodialysis

A technique in which an artificial kidney machine removes waste products from the blood patient must be hemodynamically stable to obtain vascular access for an arteriovenous fistula, graft, or temporary vascular access rapid removal of fluid, urea, and creatinine effective potassium removal temporary access can be done at bedside

COLLAPSE Patient X is on Heparin. Their test results have come in and showing a platelet count that is 50% below baseline. You walk into the patients room and notice the patient appears dyspneic and has notable irritation at their IV site. What should you do first? A. Hold the Heparin B. Administer an order of platelet transfusion C. Administer Warfarin D. Increase the Heparin infusion

A. Hold the Heparin P. 476

The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should: a. apply a sterile gauze dressing to maintain sterility. b. replace the transparent dressing every 10 days to prevent manipulation. c. assess the catheter site for redness and/or swelling. d. use the catheter for drawing blood samples to reduce patient discomfort.

C Tenderness at the insertion site, swelling, erythema or drainage should be reported to the physician. Transparent, semipermeable polyurethane dressings are recommended as they allow continuous visualization for assessment of signs of infection. Replace transparent dressings on temporary percutaneous catheters at least every 7 days and no more than once a week for tunneled percutaneous catheters unless the dressing is soiled or loose. The catheter is not used for the administration of fluids or medications or for the sampling of blood

A patient has been diagnosed with Leukemia. Which of the following symptoms would you expect to find during your assessment? A) Bradycardia, hypotension, and palpitations B) dyspnea, malaise, and hypotension C) paresthesias, facial rash, and abdominal pain D) bruising, fatigue, and bone pain.

D. Table 17-10 on page 467- 468

Peritoneal complications

Exit site infections Peritonitis Hernias Bleeding Protein loss hyperglycemia contraindicated in abdominal surgery, or hernias

Arteriovenous fistula

a thrill should be felt by palpating the fistula a bruit should be heard with stethoscope NEVER TAKE BP BLOOD DRAW OR IV IN THE ARM OF AV GRAFT OR FISTULA

CKD management

correction of fluid overload or deficit renal replacement therapy (dialysis or transplant) nutritional therapy measures to lower potassium drug therapy

Peritoneal Dialysis

dialysis in which the lining of the peritoneal cavity acts as the filter to remove waste from the blood Immediate initiation in hospital setting fewer dietary restrictions usable in hemodynamically unstable patient or with vascular access problems less cardiovascular stress preferable for diabetes takes 36 hours to have effect simplicity and can be done at home and during sleep or in intervals throughout the day

chronic kidney disease (CKD)

excess fluid volume hyperkalemia (peaked T waves, prolonged QRS) hypocalcemia hyperphosphatemia altered vitamin D anemia from low htc and hgb

Arteriovenous graft

more likely to become infected and tend to thrombose NEVER TAKE BP BLOOD DRAW OR IV IN THE ARM OF AV GRAFT OR FISTULA

Hemodialysis complications

vascular access problems dietary and fluid restrictions heparin - anticoagulation prevents thrombosis hypotension during dialysis added blood loss that contributes to anemia surgery for permanent access placement

The patient is admitted with complaints of chronic fatigue and shortness of breath. The nurse notices that the patient is tachycardic and has multiple bruises and petechiae on his body and arms. The patient also complains of frequent nosebleeds. The nurse should evaluate the patients ____________ a. complete blood count, including platelet count b. hemoglobin and hematocrit c. electrolyte values. d. blood culture results

ANS: A In addition to the general symptoms of anemia, unique disorders have their own classic clinical features. The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. The CBC with differential, which includes a platelet count, would allow for evaluation of all aspects of aplastic anemia. Hemoglobin and hematocrit help to assess for blood loss, but assessment of cause (e.g., low platelets) is more important. Electrolyte values and blood culture results are not relevant to this scenario.

The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patients temperature is elevated. The nurse should: a. assess peritoneal dialysate return. b. check the patients blood sugar. c. evaluate the patients neurological status. d. inform the provider of probable visceral perforation.

ANS: A Peritonitis is the most common complication of peritoneal dialysis therapy and is usually caused by contamination in the system. Peritonitis is manifested by abdominal pain, *cloudy peritoneal fluid, fever and chills, nausea and vomiting, and difficulty in draining fluid from the peritoneal cavity.*

The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for insertion of: a. a percutaneous catheter at the bedside. b. a percutaneous tunneled catheter at the bedside. c. an arteriovenous fistula. d. an arteriovenous graft.

ANS: A Temporary percutaneous catheters are commonly used in patients with acute kidney injury because they can be used immediately. Occasionally a percutaneous tunneled catheter is placed if the patient needs ongoing hemodialysis; however, these catheters are usually inserted in the operating room. An arteriovenous fistula is an internal, surgically created communication between an artery and a vein. This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use. Arteriovenous grafts are created by using different types of prosthetic material, most commonly polytetrafluoroethylene and Teflon. Grafts are placed under the skin and are surgically anastomosed between an artery and a vein. The graft site usually heals within 2 to 4 weeks.

Complications common to patients receiving hemodialysis include which of the following? (Select all that apply.) a. Hypotension b. Dysrhythmias c. Muscle cramps d. Hemolysis e. Air embolism

ANS: A, B, C Hypotension is common and is usually the result of preexisting hypovolemia, excessive amounts of fluid removal, or excessively rapid removal of fluid. Dysrhythmias may occur during dialysis. Causes of dysrhythmias include a rapid shift in the serum potassium level, clearance of antidysrhythmic medications, preexisting coronary artery disease, hypoxemia, or hypercalcemia from rapid influx of calcium from the dialysate solution. Muscle cramps occur more commonly in chronic renal failure. Hemolysis, air embolism, and hyperthermia are rare complications of hemodialysis.

Accepted treatments for disseminated intravascular coagulation (DIC) may require: (Select all that apply.) a. platelet infusions. b. administration of fresh frozen plasma. c. cryoprecipitate. d. packed RBCs. e. heparin.

ANS: A, B, C, D Administration of platelets is the highest priority for transfusion because they provide the clotting factors needed to establish an initial platelet plug from any bleeding site. Fresh frozen plasma is administered for fibrinogen replacement. It contains all clotting factors and antithrombin III; however, factor VIII is often inactivated by the freezing process, thus necessitating administration of concentrated factor VIII in the form of cryoprecipitate. Transfusions of packed RBCs are given to replace cells lost in hemorrhage. Although heparins antithrombin activity prevents further clotting, it may increase the risk of bleeding and may cause further problems. Its use is controversial when it is administered to patients with DIC.

The patient is admitted with anemia caused by blood loss and thrombocytopenia. His platelet count is 22,000/microliter. The patient is scheduled for a transfusion of RBCs and a transfusion of platelets. The nurse should: a. give the RBCs before the platelets. b. give the platelets before the RBCs. c. use local therapies to stop the bleeding. d. give the platelets and RBCs at the same time.

ANS: B When the patients blood does not clot because of thrombocytopenia, administration of RBCs before platelets will result in RBC loss from disrupted vascular structures. Platelets should be given first. Local therapies to stop bleeding are used when systemic anticoagulation is necessary for treatment of another health condition (e.g., myocardial infarction, ischemic stroke, or pulmonary embolism). Local procoagulants act by direct tissue contact and initiation of a surface clot.

The patient is in the critical care unit and will receive hemodialysis this morning. The nurse will: (Select all that apply.) a. evaluate morning laboratory results and report abnormal results. b. administer the patients antihypertensive medications. c. assess the dialysis access site and report abnormalities. d. weigh the patient to monitor fluid status. e. give all medications except for antihypertensive medications.

ANS: A, C, D The patient receiving hemodialysis requires specialized monitoring and interventions by the critical care nurse. Laboratory values are monitored and abnormal results reported to the nephrologist and dialysis staff. The patient is weighed daily to monitor fluid status. On the day of dialysis, dialyzable (water-soluble) medications are not given until after treatment. The dialysis nurse or pharmacist can be consulted to determine which medications to withhold or administer. Supplemental doses are administered as ordered after dialysis. Administration of antihypertensive agents is avoided for 4 to 6 hours before treatment, if possible. Doses of other medications that lower blood pressure (narcotics, sedatives) are reduced, if possible. The percutaneous catheter, fistula, or graft is assessed frequently before and after treatment; unusual findings such as loss of bruit, redness, or drainage at the site must be reported. After dialysis, the patient is assessed for signs of bleeding, hypovolemia, and dialysis disequilibrium syndrome.

Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure c. Neurologic status b. Phosphate level d. Creatinine clearance

ANS: B Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate.

A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient's abdomen appears bloated after the inflow. d. The patient has abdominal pain during the inflow phase.

ANS: B Cloudy-appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

The patient is admitted with anemia and active bleeding. The nurse suspects intravascular disseminated coagulation (DIC). Definitive diagnosis of DIC is made by evidence of: a. a decrease in fibrin degradation products. b. an increased D-dimer level. c. thrombocytopenia. d. low fibrinogen levels.

ANS: B Evidence of factor depletion in the form of thrombocytopenia and low fibrinogen levels (less than 100) is seen in the early phase; however, definitive diagnosis is made by evidence of excess fibrinolysis detectable by elevated fibrin degradation products (FDP more than 10), an increased D-dimer level (more than 0.5), or a decreased antithrombin III level.

Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis: a. is more frequently used for acute kidney injury. b. uses the patients own semipermeable membrane (peritoneal membrane). c. is not useful in cases of drug overdose or electrolyte imbalance. d. is not indicated in cases of water intoxication.

ANS: B Peritoneal dialysis is the removal of solutes and fluid by diffusion through a patients own semipermeable membrane (the peritoneal membrane) with a dialysate solution that has been instilled into the peritoneal cavity. This renal replacement therapy is not commonly used for the treatment of acute kidney injury because of its comparatively slow ability to alter biochemical imbalances. Clinical indications for peritoneal dialysis include acute and chronic kidney injury, severe water intoxication, electrolyte disorders, and drug overdose.

The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should: a. prepare to assist with a routine dialysis catheter change to replace the existing catheter. b. evaluate the patient for signs and symptoms of infection. c. teach the patient that the catheter is designed for long-term use. d. use one of the three lumens for fluid administration.

ANS: B Routine replacement of hemodialysis catheters to prevent infection is not recommended. The decision to remove or replace the catheter is based on clinical need and/or signs and symptoms of infection. The typical catheter has a single or double lumen and is designed only for short-term renal replacement therapy during acute situations. The catheter is not used for fluid and medication administration.

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patient's central venous pressure (CVP) is decreased. c. The patient has a level 7 (0- to 10-point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevated.

ANS: B The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

During routine hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check the blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.

ANS: B The patient's complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions may also be appropriate based on the blood pressure obtained.

The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. His blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; he has not voided in 8 hours and his bladder is not distended. The nurse anticipates an order for stat administration of: a. a blood transfusion. b. fluid replacement with 0.45% saline. c. infusion of an inotropic agent. d. an antiemetic.

ANS: B This scenario indicates hypovolemia from the nausea and vomiting, requiring volume replacement. Hypovolemia resulting from large urine or gastrointestinal losses often requires the administration of a hypotonic solution, such as 0.45% saline. Blood products would be indicated only in the presence of bleeding following assessment of hemoglobin and hematocrit levels. The inotrope is contraindicated in the presence of volume depletion. An antiemetic may be needed; however, the priority to prevent shock and acute kidney injury is fluid administration.

The patient is admitted with multiple myeloma. The nurse assesses the patient and is aware that the symptom most unique to this disease is: a. fever. b. night sweats. c. bone pain. d. lymph node enlargement.

ANS: C Bone pain is common in multiple myeloma, whereas lymph node enlargement is more representative of lymphoma. Fever is particularly difficult to interpret because it may be a manifestation of the disease process or may accompany an infectious complication. General signs and symptoms such as fatigue, malaise, myalgias, activity intolerance, and night sweats are nonspecific indicators of immune disease.

The patient is on intake and output (I&O) as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should: a. draw a trough level after the next dose of antibiotic. b. obtain an order to place the patient on fluid restriction. c. assess the patients lungs. d. insert an indwelling catheter.

ANS: C The scenario indicates retention of fluid; therefore, the nurse must assess for symptoms of fluid overload, for example, by auscultating the lung fields. Adequate hydration is essential and fluid restriction would be determined by the physician upon physical examination and analysis of laboratory results. An indwelling urinary catheter should not routinely be inserted because it increases the risk of infection. A trough level is drawn just before the next dose of a drug is given and is an indicator of how the body has cleared the drug; it would not be done secondary to imbalanced intake and output.

The patient has just returned from having an arteriovenous fistula placed. The patient asks, When will they be able to use this and take this other catheter out? The nurse should reply, a. It can be used immediately so the catheter can come out anytime. b. It will take 2 to 4 weeks to heal before it can be used. c. The fistula will be usable in about 4 to 6 weeks. d. The fistula was made using graft material so it depends on the manufacturer.

ANS: C An arteriovenous fistula is an internal, surgically created communication between an artery and a vein. This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use.

The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of: a. dialyzer membrane incompatibility. b. a shift in potassium levels. c. dialysis disequilibrium syndrome. d. hypothermia.

ANS: C Dialysis disequilibrium syndrome often occurs after the first or second dialysis treatment or in patients who have had *sudden, large decreases in BUN and creatinine levels* as a result of the hemodialysis. Because of the blood-brain barrier, dialysis does not deplete the concentrations of BUN, creatinine, and other uremic toxins in the brain as rapidly as it does those substances in the extracellular fluid. An osmotic concentration gradient established in the brain allows fluid to enter until the concentration levels equal those of the extracellular fluid. The extra fluid in the brain tissue creates a state of *cerebral edema for the patient, which results in severe headaches, nausea and vomiting, twitching, mental confusion, and occasionally seizures.* Dialyzer membrane incompatibility may cause hypotension. Hyperthermia, not hypothermia, may result if the temperature control devices on the dialysis machine malfunction. Potassium shifts may occur but would be manifested in cardiac dysrhythmias.

The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should: a. reassess the patient in an hour. b. raise the arm above the level of the patients heart. c. notify the provider immediately. d. apply warm packs to the fistula site and reassess.

ANS: C Inadequate collateral circulation past the fistula or graft may result in loss of this pulse. The physician is notified immediately if no bruit is auscultated, no thrill is palpated, or the distal pulse is absent. Loss of bruit and thrill indicate a loss of blood flow most likely due to clotting. The patient will need to return to surgery as soon as possible for declotting. Raising the arm above the level of the heart will not help. Warm packs may or may not help.

Critical to caring for the immunocompromised patient is the understanding that: a. the immunocompromised patient has normal white blood cell (WBC) physiology. b. the immunosuppression involves a single element or process. c. infection is the leading cause of death in these patients. d. immune incompetence is symptomatic even without pathogen exposure.

ANS: C Infection is the leading cause of death in the immunocompromised patient. The immunocompromised patient is one with defined quantitative or qualitative defects in WBCs or immune physiology. The defect may be congenital or acquired, and may involve a single element or multiple processes. Regardless of the cause, the physiological outcome is immune incompetence, with lack of normal inflammatory, phagocytic, antibody, or cytokine responses. Immune incompetence is often asymptomatic until pathogenic organisms invade the body and create infection.

The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week. The patient complains of general malaise and is tachypneic. An arterial blood gas is ordered and shows that the patients pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to: a. administer morphine to slow the respiratory rate. b. prepare for intubation and mechanical ventilation. c. administer intravenous sodium bicarbonate. d. cancel tomorrows dialysis session.

ANS: C Metabolic acidosis is the primary acid-base imbalance seen in acute kidney injury. Treatment of metabolic acidosis depends on its severity. Patients with a serum bicarbonate level of less than 15 mEq/L and a pH of less than 7.20 are usually treated with intravenous sodium bicarbonate. The goal of treatment is to raise the pH to a value greater than 7.20. Rapid correction of the acidosis should be avoided, because tetany may occur as a result of hypocalcemia. Renal replacement therapies also may correct metabolic acidosis because it removes excess hydrogen ions and bicarbonate is added to the dialysate and replacement solutions; therefore, dialysis would not be cancelled. The tachypnea is a compensatory mechanism for the metabolic acidosis, and treatments to decrease the respiratory rate are not indicated. Treatment is aimed at correcting the metabolic acidosis, and this scenario does not provide data to support the need for intubation.

The patient is being seen for complaints of general malaise, fatigue, and shortness of breath. The patient states that he has felt this way since he had a cold 6 weeks earlier. The nurse should expect the provider to order: a. lymph node biopsy. b. differential blood count only. c. complete blood count (CBC) with differential. d. Bone marrow biopsy.

ANS: C The first screening diagnostic tests performed to detect hematological or immunological dysfunction are a Complete Blood Count (CBC) with differential and a coagulation profile. The CBC evaluates the cellular components of blood. The CBC reports the total RBC count and RBC indices, hematocrit, hemoglobin, WBC count and differential, platelet count, and cell morphologies. The most invasive microscopic examinations of the bone marrow or lymph nodes are reserved for circumstances when laboratory tests are inconclusive or when an abnormality in cellular maturation is suspected (e.g., aplastic anemia, leukemia, or lymphoma). A differential laboratory test is not done without the CBC first. A bone marrow biopsy is not warranted; it would only be done if preliminary studies indicated a hematological problem.

An advantage of peritoneal dialysis is that: a. peritoneal dialysis is time intensive. b. a decreased risk of peritonitis exists. c. biochemical disturbances are corrected rapidly. d. the danger of hemorrhage is minimal.

ANS: D Advantages of peritoneal dialysis include that the equipment is assembled easily and rapidly, the cost is relatively inexpensive, the danger of acute electrolyte imbalances or hemorrhage is minimal, and dialysate solutions can be individualized. In addition, automated peritoneal dialysis systems are available. Disadvantages of peritoneal dialysis include that it is time intensive, requiring at least 36 hours for a therapeutic effect to be achieved; biochemical disturbances are corrected slowly; access to the peritoneal cavity is sometimes difficult; and the risk of peritonitis is high.

31. The patient is in progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should: a. draw blood from the left arm. b. take blood pressures from the left arm. c. start a new intravenous line in the left lower arm. d. auscultate the left arm for a bruit and palpate for a thrill.

ANS: D An arteriovenous fistula should be auscultated for a bruit and palpated for the presence of a thrill or buzz every 8 hours. The extremity that has a fistula or graft must never be used for drawing blood specimens, obtaining blood pressure measurements, administering intravenous therapy, or giving intramuscular injections. Such activities produce pressure changes within the altered vessels that could result in clotting or rupture.

The nurse is caring for a patient diagnosed with anemia. This mornings hematocrit level is 24%. Platelet level is 200,000/microliter. The nurse can expect to: a. continue monitoring the patient, as this hematocrit is normal. b. administer platelets to help control bleeding. c. give fresh frozen plasma to decrease prothrombin time. d. provide RBC transfusion because this level is below the normal threshold.

ANS: D In general, a threshold for RBC transfusion is considered a hematocrit of 28% to 31%, based on the patients cardiovascular tolerance. If angina or orthostasis is present, a higher threshold may be maintained. The threshold for transfusing platelets is usually between 20,000 and 50,000/microliter. Cryoprecipitate is usually infused if the fibrinogen level is less than 100 mg/dL. Fresh frozen plasma is used to correct a prolonged prothrombin time and partial thromboplastin time or a specific factor deficiency.

A patient complains of leg cramps during hemodialysis. The nurse should a. massage the patient's legs. c. give acetaminophen (Tylenol). b. reposition the patient supine. d. infuse a bolus of normal saline.

ANS: D Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

The patient is complaining of severe joint pain as well as fatigue and shortness of breath. The nurse notices that the patients joints are swollen and his legs are edematous. The nurse realizes that these are symptoms of: a. anemia reflective of low volume. b. aplastic anemia. c. hemolytic anemia. d. sickle cell anemia.

ANS: D Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual development. In crisis, the sickle cell patient often has decreased urine output, peripheral edema, and signs of uremia because renal tissue perfusion is impaired as a result of sluggish blood flow. Decreased circulating volume is manifested by clinical findings reflective of low blood volume (e.g., low right atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis). The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the spleen or liver. These findings result from the increased destruction of RBCs, their sequestration (abnormal distribution in the spleen and liver), and the accumulation of breakdown products.

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Review the chart for the patient's current creatinine level. d. Check the medical record for the most recent potassium level.

ANS: D The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias.

The nurse understands that when clots breakdown in a patient with a hematological disorder, that which value will increase? a. hemoglobin. b. white blood cell count. c. vitamin K. d. fibrin split products.

ANS: D When plasmin digests fibrinogen, fragments known as fibrin split products, or fibrin degradation products, are produced and function as potent anticoagulants. Fibrin split products are not normally present in the circulation but are seen in some hematological disorders like DIC. as well as with thrombolytic therapy. Vitamin K is necessary for synthesis of factors II, VII, IX, X that are needed for clotting to occur. Hemoglobin may decrease if the patient is bleeding, and WBCs are not relevant to this scenario.

A 40 year old male patient presents to the ER with bone pain, weakness, fatigue, hypercalcemia and a history of osteoporosis. His initial urine output is 300cc and he reports aching throughout his entire body. The Physician on call is requesting a test for Bence-Jones protein presence in the urine. What condition is the physician suspecting this patient may be presenting with? A. Leukemia B. Lymphoma C. Multiple Myeloma D. Aplastic anemia

Ans: C This patient presents with symptoms associated with the diagnosis of Multiple myeloma. The physician has ordered a urine test looking for Bence Jones protein in the urine which can be a diagnostic confirmation of the diagnosis of Multiple Myeloma. Bence Jones is a protein found in the urine and through biopsy to confirm the diagnosis of Multiple cell myeloma.

The nurse is caring for a 30 year old male patient with HIV who has come in for his biannual CD4 test. The patient's test results come back and the CD4 count is 396. Knowing the normal levels for CD4 count, the patient is concerned their HIV has progressed to AIDs. The nurse's response is based on the knowledge that: (select all that apply) A. A patient is not diagnosed with AIDs until they have developed an opportunistic infection. B. The normal CD4 count ranges from 500-1,500 meaning the patient has developed AIDs. C. AIDs is diagnosed when the patient's CD4 count is less than 200. D. The patient does not have AIDs until their viral load has doubled since the last visit. E. HIV does not become AIDs until the patient has had the disease for at least 10 years.

Answer: A, C Rationale: Diagnostic criteria of AIDs includes a CD4 count below 200 or the presence of an opportunistic infection. Disease progression from HIV to AIDs is not dependent on the viral load or how long the patient has had the disease.

A patient with severe Pernicious anemia is being discharged home and requires teaching. Which statement by the patient demonstrates they understood instructions about the treatment regime? A) "I will require one injection every 6 months until my Vitamin B12 levels are therapeutic and then I'm done." B) "Initially, I will need weekly injections of Vitamin B12 and then monthly injections for maintenance, which will be a lifelong regime. C) "I will need vitamin B12 injections for a month and then I can take a low dose of oral vitamin B12." D) "When I start to feel weak and short of breath I need to call the doctor so I can schedule an appointment for a Vitamin B12 injection."

Answer: B Pernicious anemia (B12 deficiency) is diagnosed with a schilling test and requires lifelong treatment of B12 IM or deep SC injections. The triad for this anemia is a sore tongue, weakness, and paresthesias Table 17-8 pages 457-459

You are caring for a patient with a history of diabetes mellitus and ovarian cysts who came into the ED with jaundice, itching and sensitivity in the upper left quadrant. What type of anemia would you expect to be diagnosed? A. Sickle cell anemia B. Folic acid deficiency anemia C. Hemolytic anemia D. Aplastic Anemia

Answer: C. Hemolytic Anemia p. 457-459

The nurse writes a diagnosis of "potential for fluid volume deficit related to bleeding" for a client diagnosed with DIC. Which would be an appropriate goal? A. The patient's clot formations will resolve in two days B. The saturation of the patient's dressings will be documented C. The patient will learn to use lemon-glycerin swabs for oral care D. The patient's urine output will be > 30 mL per hour

Answer: D An appropriate goal would be to maintain urine output >30 mL an hour because DIC "thrombosis leads to organ ischemia and necrosis that may be manifested as changes in mental status, angina, oliguria, or non-specific hepatitis". (p. 476)