230 exam 2
Acute dialysis is indicated during which situation? Metabolic alkalosis Impending pulmonary edema Hypokalemia Dehydration
Impending pulmonary edema Explanation: Acute dialysis is indicated when there is a high and increasing level of serum potassium, fluid overload, or impending pulmonary edema, or increasing acidosis.
Which of the following site is the source of most microbes leading to bacterial infection? Respiratory tract Skin Intestinal tract Mucous membranes
Intestinal tract Explanation: When the wound is healing, it must be protected from infection. A primary source of bacterial infection is the patient's intestinal tract, the source of most microbes. The respiratory tract, skin, and mucous membranes are not the source of most microbes.
A 54-year-old male patient is admitted to the hospital with a case of severe dehydration. The nurse reviews the patient's laboratory results. Which of the following results are consistent with the diagnosis? Select all that apply. Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Serum glucose of 90 mg/dL Hematocrit level of 48% Urine specific gravity of 1.03 Blood urea nitrogen (BUN) of 23 mg/dL
Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Urine specific gravity of 1.03 Severe dehydration is associated with an increased BUN (N = 10 to 20 mg/dL), serum osmolality (N = 275 to 300 mOsm/kg), serum sodium (N = 135 to 145 mEq/L) and urine specific gravity (N = 1.01 to 1.025). Glucose and hematocrit levels would also be elevated but are within normal range for this question.
A nurse is caring for a client on bedrest with end-stage kidney disease. What major manifestation of uremia should the nurse expect to decrease with an exercise plan? Increased secretion of parathormone Hyperparathyroidism A decreased serum phosphorus level Bone demineralization
Bone demineralization Explanation: Uremic bone disease, often called renal osteodystrophy, develops from the complex changes in calcium, phosphate, and parathormone balance. Clients on bedrest with end-stage kidney disease will have increased bone demineralization. Bone disease will cause a retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels. Hypoparathyroidism and decreased secretion of the parathormone will occur with the client on bedrest.
Which zone consists of the area where the injury is most severe and deepest? Coagulation Stasis Hyperemia Necrosis
Coagulation Explanation: The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. There is no zone of necrosis.
A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? Fluid status Nutritional status Risk of infection Psychosocial coping
Fluid status Explanation: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.
Based on the pathophysiologic changes that occur as renal failure progresses, the nurse identifies the following indicators associated with the disease. Select all that apply. Hypocalcemia Hyperalbuminemia Anemia Metabolic alkalosis Hyperkalemia
Hyperkalemia Anemia Hypocalcemia Explanation: Hyperkalemia is due to decreased potassium excretion and excessive potassium intake. Metabolic acidosis results from decreased acid secretion by the kidney. A damaged glomerular membrane causes excess protein loss.
A client with chronic kidney disease becomes confused and reports abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which lab value? Elevated urea levels Elevated white blood cells Hyperkalemia Hypocalcemia
Hyperkalemia Explanation: Hyperkalemia is the life-threatening effect of renal failure. The client can become apathetic; confused; and have abdominal cramping, dysrhythmias, nausea, muscle weakness, and numbness of the extremities. Symptoms of hypocalcemia are muscle twitching, irritability, and tetany. Elevation in urea levels can result in azotemia, which can be exhibited in fluid and electrolyte and/or acid-base imbalance. Elevation of WBCs is not indicated.
A child tips a pot of boiling water onto his bare legs. The mother should: Avoid touching the burned skin and take the child to the nearest emergency department. Cover the child's legs with ice cubes secured with a towel. Immerse the child's legs in cool water. Liberally apply butter or shortening to the burned areas.
Immerse the child's legs in cool water. Explanation: The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage.
A client is admitted to the burn unit after being transported a long distance. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? Cellulitis Venous thromboembolism (VTE) Ischemia Referred pain
Ischemia Explanation: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur distal to the injury site.
With which condition should the nurse expect that a decrease in serum osmolality will occur? Uremia Kidney failure Influenza Hyperglycemia
Kidney failure Explanation: Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body.
The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions? Gastrointestinal system Musculoskeletal system Neurological system Endocrine system
Neurological system Explanation: A client with a calcium level of 4.0 mg/dL has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.
A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase? Oliguria Restored glomerular function Acute tubular necrosis Diuresis
Oliguria Explanation: During the second phase, the oliguric phase, oliguria occurs. Diuresis occurs during the third or diuretic phase. Acute tubular necrosis (ATN) occurs during the first, or initiation, phase in which reduced blood flow to the nephrons leads to ATN. Restoration of glomerular function, if it occurs, occurs during the fourth, or recovery, phase.
Which period of acute renal failure is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys? Oliguria Diuresis Initiation Recovery
Oliguria Explanation: The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys, such as urea and creatinine. The initiation periods begins with the initial insult and ends when oliguria develops. The diuresis period is marked by a gradual increase in urine output. The recovery period signals the improvement of renal function and may take 6 to 12 months.
Nursing assessment for the patient receiving peritoneal dialysis would include which of the following to detect the most serious complication of this procedure? Inspect the catheter site for leakage of dialysate. Palpate the abdominal wall for rebound tenderness. Measure fluid drainage to estimate incomplete recovery of fluid. Observe for evidence of bleeding.
Palpate the abdominal wall for rebound tenderness. Explanation: Peritonitis is the most serious complication of peritoneal dialysis. To detect rebound tenderness, the nurse presses one hand firmly into the abdominal wall and quickly withdraws the hand. Rebound tenderness exists when pain occurs upon removal; this pain is associated with inflammation of the peritoneal cavity.
A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? escharotomy debridement silvadene application allograft
escharotomy Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.
A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure? anemia fluid, electrolyte status histamine hemoconcentration
hemoconcentration Explanation: The client with a burn experiences hemoconcentration when the plasma component of blood is lost or trapped. Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure.
Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting? pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34 pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28
pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis, where only gastric fluid is lost. The other results do not represent metabolic alkalosis.
A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: fluid resuscitation. infection. body image. pain management.
pain management. Explanation: With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.
A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as 9%. 27%. 36%. 18%.
18%. Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the total body surface area (TBSA), quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%). In this case the client's abdomen (9%) and front of the left leg (9%) add up to 18%.
A client diagnosed with chronic kidney disease is hospitalized and receiving hemodialysis 3 days a week. When creating the plan of care, which actions will be included? Select all that apply. Ensure that the client moves the extremity with the vascular access site as little as possible. Assess for a thrill or bruit over the vascular access site during every shift. Change the dressing over the vascular access site at least every 12 hours. Assess access site pain daily. Utilize the vascular access site for infusion of IV fluids.
Assess for a thrill or bruit over the vascular access site during every shift. Assess access site pain daily. Explanation: The bruit, or "thrill," over the venous access site must be evaluated at least every shift. Access site should be observed daily for redness, swelling, bleeding, drainage, heat, or pain. Frequent dressing changes are unnecessary and the client does not normally need to immobilize the site. The site must not be used for purposes other than dialysis.
The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for? Cerebral edema Red blood cell hydrolysis Red blood cell crenation Renal failure
Cerebral edema Explanation: Treatment of hypernatremia consists of a gradual lowering of the serum sodium level by the infusion of a hypotonic electrolyte solution (e.g., 0.3% sodium chloride) or an isotonic nonsaline solution (e.g., dextrose 5% in water [D5W]). D5W is indicated when water needs to be replaced without sodium. Clinicians consider a hypotonic sodium solution to be safer than D5W because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema. It is the solution of choice in severe hyperglycemia with hypernatremia. A rapid reduction in the serum sodium level temporarily decreases the plasma osmolality below that of the fluid in the brain tissue, causing dangerous cerebral edema.
Compliance with a renal diet is a difficult lifestyle change for a client on hemodialysis. The nurse should reinforce nutritional information. Which teaching point(s) should be included? Select all that apply. Consume nonbiologic protein only. Restrict fluids based on the previous day's output. Increase potassium intake. Eat a variety of canned vegetables. Eat foods such as milk, fish, and eggs.
Eat foods such as milk, fish, and eggs. Restrict fluids based on the previous day's output. Explanation: With hemodialysis, protein restriction is necessary. At least half of all protein eaten should come from biologic sources such as eggs, meats, and plant-based groups. Sodium should be reduced. Canned vegetables are high in sodium. Potassium is restricted to decrease cardiac risk. The client's daily fluid intake should be based on the previous day's urine output.
The nurse is admitting a client with prerenal acute kidney injury (AKI). Which health history is identified by the nurse to be most significant for this diagnosis? Select all that apply. Heart failure Aminoglycoside toxicity Ureterolithiasis Obstructed renal artery Glomerulonephritis
Heart failure Obstructed renal artery Prerenal AKI is caused by reduced blood flow, BP, or perfusion to the kidney with a resulting decrease in the glomerular filtration rate (GFR) and urine output. A wide variety of factors are associated with a decrease of arterial blood reaching the renal artery (which supplies the kidney) and can include thrombosis (clot), hemorrhage, vasodilation, to low cardiac output states. By causing inadequate renal perfusion, heart failure and renal artery obstruction can lead to prerenal failure. Intrarenal or intrinsic AKI is the result of actual parenchymal damage to the glomeruli or kidney tubules. Glomerulonephritis and aminoglycoside toxicity are intrarenal causes. Postrenal AKI is the result of a mechanical or functional obstruction resulting in decreased urinary flow. Ureterolithiasis is a postrenal cause.
heart rate and urine output
Heart rate Urine output Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits.
A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, which findings will be expected in this phase? Select all that apply. Hypernatremia Increased urine output Metabolic alkalosis Hyperkalemia Decreased hematocrit
Hyperkalemia Hypernatremia Decreased hematocrit Metabolic alkalosis Explanation: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis. The urine output would be decreased in this phase and only increased in the diuretic phase.
The nurse is caring for a client hospitalized with a diagnosis of acute kidney injury (AKI) experiencing hyperkalemia with a peaked T-wave. Which medication therapy will the nurse prepare to implement? Select all that apply. Cyclosporine Oral polystyrene sulfonate Gentamicin IV insulin IV Glucose
IV insulin IV Glucose Oral polystyrene sulfonate Explanation: Hyperkalemia with EKG changes, such as a peaked T-wave, can be treated temporarily with IV insulin, given with glucose to prevent hypoglycemia, to temporarily shift potassium back into the cells. Calcium may be administered to treat the cardiotoxicity that has developed secondary to hyperkalemia since it directly antagonizes the membrane effects of hyperkalemia. It is important to understand that hyperkalemia is the most common metabolic cause of death in clients with AKI. Additional measures for hyperkalemia may include administering cation exchange resins (either sodium [sodium polystyrene sulfonate] or calcium [calcium polystyrene sulfonate]) orally, via NG tube, or by retention enema. Both gentamicin and cyclosporine are nephrotoxic and have no therapeutic value in this situation.
Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply. Monitor intake and output every shift. Offer a diet with fruit juices and citrus fruits. Administer the ordered furosemide 60 mg po. Administer the ordered potassium 40 mg IV push. Administer the ordered Kayexalate enema.
Offer a diet with fruit juices and citrus fruits. Monitor intake and output every shift. Explanation: Hypokalemia is a potassium level less than 3.5 mEq/L. Nurses must have knowledge of this life-threatening imbalance. The nurse would complete appropriate interventions such as offering a diet containing sufficient potassium, which includes fruits and vegetables, and monitoring the intake and output. Approximately 40 mEq of potassium is lost for every liter of urine output. Potassium is never administered via IV push; if IV potassium is needed, it is administered via infusion pump and with careful monitoring (e.g., EEG, BUN/creatinine, urine output) to ensure hyperkalemia does not result.
The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance? Encourage oral fluids. Offer a prescribed antiemetic medication. Remove the Hemovac. Suggest a fluid restriction.
Offer a prescribed antiemetic medication. Explanation: When calculating the intake and output of a client, it is essential to understand that the normal average intake is 2500 mL in adults. Ranges are often noted at 1800 to 3000 mL. Because the client is vomiting, offering a prescribed antiemetic medication would decrease the output from emesis and increase the input as the client may be more accepting of oral fluids. The client should be encouraged more oral intake once vomiting has subsided, but if not possible, intravenous fluids should be increased to avoid dehydration A fluid restriction could cause dehydration. Removing the Hemovac will decrease documented output but may lead to an internal infection from fluid accumulation.
A client scheduled for a CT scan of the abdomen with contrast has a baseline creatinine level of 2.3 mg/dL. In preparing this client for the procedure, the nurse anticipates what orders? Hemodialysis immediately prior to the CT scan Preprocedure hydration with 0.9% NaCl Administration of acetylcysteine Obtain a creatinine clearance by collecting a 24-hour urine specimen.
Preprocedure hydration with 0.9% NaCl Explanation: Radiocontrast-induced nephropathy (CIN) is a major cause of hospital-acquired acute kidney injury. Baseline levels of creatinine greater than 2 mg/dL identify the client as being high risk. Isotonic hydration, such as with normal saline (0.9% NaCl), is recommended before, during, and after contrast dye exposure in at-risk individuals. The use of N-acetylcysteine, orally or intravenously, and bicarbonate to prevent CIN have not demonstrated consistent benefit; rather it is suggested that the smallest amount of contrast agent be used, and that repetitive, closely spaced studies are avoided. Nothing in the scenario indicates the need for hemodialysis. A creatinine clearance is not necessary prior to a CT scan with contrast.
A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? Promoting thermoregulation Providing education to the client and family Treating infection Monitoring fluid and electrolyte imbalances
Providing education to the client and family Explanation: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery.
A client is being transferred to the emergency department via ambulance with a scald injury from a hot kettle. Which variables will the nurse consider when determining the depth of burn? Select all that apply. How the injury occurred What type of medication the client takes Duration of agent's contact with skin Temperature of the burning agent Thickness of the skin at burn site
Temperature of the burning agent Duration of agent's contact with skin Thickness of the skin at burn site How the injury occurred Explanation: The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. Medication that is taken does not assist with the determination of burn depth.
A patient is placed on hemodialysis for the first time. The patient complains of a headache with nausea and begins to vomit, and the nurse observes a decreased level of consciousness. What does the nurse determine has happened? Too much fluid was pulled off during dialysis. The dialysis was performed too rapidly. The patient is experiencing a cerebral fluid shift. The patient is having an allergic reaction to the dialysate.
The patient is experiencing a cerebral fluid shift. Dialysis disequilibrium results from cerebral fluid shifts. Signs and symptoms include headache, nausea and vomiting, restlessness, decreased level of consciousness, and seizures. It is rare and more likely to occur in AKI or when BUN levels are very high (exceeding 150 mg/dL).
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? Potassium level of 3.5 mEq/L Blood glucose level of 200 mg/dl Hematocrit (HCT) of 35% White blood cell (WBC) count of 20,000/mm3
White blood cell (WBC) count of 20,000/mm3 Explanation: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia (evidenced by a blood glucose level of 200 mg/dl) occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.
Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern? Zone of stasis Zone in burn center Zone of coagulation Zone of hyperemia
Zone of stasis Explanation: The zone of stasis lies outside the burn center and zone of coagulation. This is where the blood vessels are damaged, but tissue has the potential to survive with proper management. The center zone or zone of coagulation is the deepest area of injury and is considered the zone of irreversible damage, placing the focus on saving the surrounding tissues. The zone of hyperemia is the area of least injury.
A client being treated for a chronic illness has a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which assessment findings will the nurse expect to assess in the client? Select all that apply. Muscle weakness Hyperactive reflexes Anorexia Numb fingers Abdominal distention
Anorexia Muscle weakness Abdominal distention Explanation: A normal serum potassium level ranges from 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Clinical signs and symptoms of a low potassium level include anorexia, muscle weakness, and hypoactive reflexes. Hyperactive reflexes are associated with
The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? Rehabilitation Acute Immediate resuscitative Emergent
Acute Explanation: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.
The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance? An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. A 45-year-old client who had a laparoscopic appendectomy 24 hours ago and is being advanced to a regular diet. A 79-year-old client admitted with a diagnosis of pneumonia. A 66-year-old client who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift.
An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. Explanation: The 82-year-old client has three risk factors: advanced age, tube feedings, and diuretic usage (torsemide). This client has the highest risk for fluid and electrolyte imbalances. The 45-year-old client has the risk factor of surgery, the 79-year-old client has the risk factor of advanced age, and the 66-year-old client has the risk factors of age and the bile drain, but none of these are the client at the highest risk.
The nurse is reviewing lab work on a newly admitted client. Which diagnostic stud(ies) confirms the nursing problem statement of dehydration. Select all that apply. Absence of ketones in urine An elevated hematocrit level A low urine specific gravity Low protein level in the urine Electrolyte imbalance
An elevated hematocrit level Electrolyte imbalance Explanation: Dehydration is a common primary or secondary diagnosis in health care. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.
The nurse is caring for a patient with a medical history of untreated CKD that has progressed to ESKD. Which of the following serum values and associated signs and symptoms will the nurse expect the patient to exhibit? Select all that apply. Magnesium 1.5 mg/dL; mood changes and insomnia Chloride 90 mEq/L; irritability and seizures Phosphate 5.0 mg/dL; tachycardia and nausea and emesis Calcium 7.5 mg/dL; hypotension and irritability Potassium 6.4 mEq/L; dysrhythmias and abdominal distention
Calcium 7.5 mg/dL; hypotension and irritability Potassium 6.4 mEq/L; dysrhythmias and abdominal distention Phosphate 5.0 mg/dL; tachycardia and nausea and emesis Explanation: Decreased calcium, increased potassium, and increased phosphate levels are associated with ESKD, along with the signs and symptoms associated with these serum values. Decreased magnesium and chloride levels are not associated with ESKD.
The nurse is visiting the home of a client who is receiving at-home peritoneal dialysis therapy. Which finding indicates to the nurse that the client is developing peritonitis? Cloudy dialysate effluent Bloody effluent Report of pronounced hunger Low back pain
Cloudy dialysate effluent Explanation: Most complications of peritoneal dialysis are minor; however, if left untreated, it can lead to serious consequences. Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate effluent. Low back pain can occur from the weight of the fluid in the abdomen. Bloody effluent can occur in young menstruating female clients. It is also common during the first few exchanges after a new catheter is inserted, which most often clears up after several exchanges. Clients with peritonitis are more likely to report anorexia than pronounced hunger.
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? Confusion Headache Nausea Hallucinations
Confusion Explanation: Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.
A client experienced a 33% total body surface area (TBSA) burn 72 hours ago. The nurse observes that the hourly urine output has been steadily increasing over the past 24 hours. How will the nurse best respond to this finding? Select all that apply. Report the client's early signs of acute kidney injury (AKI) Administer sodium chloride as ordered to compensate for this fluid loss Understand that capillaries are regaining integrity Obtain an order to reduce the rate of the client's IV fluid infusion Recognize that the client is experiencing an expected onset of diuresis
Recognize that the client is experiencing an expected onset of diuresis Understand that capillaries are regaining integrity As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI.
The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality? Provide intravenous fluid therapy Administer intravenous antibiotics Regular bathing of burned areas Remove burned tissue
Remove burned tissue Explanation: The acute/intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of body functions. One of the most important medical interventions for clients with burns that positively affect mortality is early excision (surgical removal of tissue). The presence of open wounds or invasive organisms triggers the response to a large burn injury, a systemic cascade of events. Excising the necrotic tissue can ameliorate this response and preserve underlying viable tissue. Intravenous antibiotics and intravenous fluid therapy are not identified as interventions to reduce the risk of mortality. Regular bathing of unburned areas and changing linens can help prevent infection, but burned areas are not bathed.