Question 1

The nurse assesses a client during the dwell time of a peritoneal dialysis cycle. Which assessment would require immediate intervention?

Accepted Answer

During peritoneal dialysis, dialysate is infused into the abdominal cavity and the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid drains out via gravity. During the instillation and dwell portions of the cycle, clients are monitored closely for indications of respiratory distress (eg, difficulty breathing, rapid respirations, crackles) that can result from instilling the dialysate too rapidly, overfilling of the abdomen, or fluid entering the thoracic cavity (Option C). Crackles can also occur if over time there is more dialysate infused than is removed (fluid gain). (Option A) Clients receive peritoneal dialysis due to chronic kidney failure. The client's blood pressure is likely elevated secondary to the renal failure. This assessment is important to monitor, but crackles in the lungs are the priority. (Option B) Clients with renal failure typically have electrolyte abnormalities (eg, acidosis) that lead to nausea. This is not a priority. (Option D) Edema in the extremities can also indicate volume overload. However, this could be due to many other factors (eg, blood pressure medications such as amlodipine) or fluid overload from kidney disease. It is not a priority over crackles, which indicate direct seeping of excess peritoneal cavity fluid into the thorax through diaphragmatic channels. Educational objective: Clients receiving peritoneal dialysis should be monitored carefully for signs and symptoms of respiratory compromise, including difficulty breathing, rapid respirations, and crackles.

Question 2

A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye.  The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation.  What action is appropriate at this time?

Accepted Answer

11ecbb05_ca90_cb16_b433_7ff40e69ed42_MD0009_00 Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns (eg, ammonia, cement, lye-containing drain cleanser) are particularly dangerous as they will quickly penetrate deep into the eye, causing severe, irreversible damage. For all types of ocular chemical burns, copious eye irrigation with sterile saline or water should begin immediately to flush the chemical irritant out of the eye (Option C). Before transport to an emergency care facility, tap water can be used for eye irrigation. If transported by ambulance, emergency care personnel continue irrigation during transport with IV tubing or a Morgan lens. Irrigation is continued until the pH of the eye returns to normal (pH 6.5-7.5), which typically requires 30-60 minutes depending on the type of chemical. (Option A) Depending on the severity of the burn, anesthetic eye drops may be instilled prior to irrigation because ocular burns are very painful, but systemic analgesia is not a priority. (Option B) Care of ocular burns may include covering the eye with an eye patch and use of eye drops to prevent eye muscle spasms; however, eye irrigation should be performed first. (Option D) The Snellen eye chart is commonly used to assess visual acuity. However, eye irrigation is essential and should not be delayed. Educational objective: Ocular chemical burns require immediate, copious irrigation with sterile saline or water to flush the chemical irritant out of the eye. Irrigation is continued until the pH of the eye returns to normal, which typically takes 30-60 minutes.

Question 3

A clinic nurse receives messages on 4 clients. Which client should the nurse call back first?

Accepted Answer

The kidneys regulate fluid volume and blood pressure. Because renal damage often results in elevated blood pressure, clients with chronic kidney disease are at risk for uncontrolled hypertension and hypertensive emergencies. Hypertensive encephalopathy is a type of hypertensive crisis characterized by nausea, vomiting, and headache (Option B). Treatment is urgent (ie, within 1 hour) to prevent damage to the heart, kidney, and brain. The client should check blood pressure at home, if possible, and then proceed to the emergency department for further assessment and treatment (eg, titration of antihypertensive medication). (Option A) Celiac disease is an autoimmune disorder that interferes with the digestion of gluten. Diarrhea and foul-smelling stools are expected findings for this client, especially if noncompliant with a gluten-free diet. (Option C) Nausea and diarrhea are possible side effects of many antibiotics. The nurse should inquire about fever and frequency of diarrhea, as antibiotic use could also cause Clostridium difficile infection. However, this does not take priority over a client with a potentially life-threatening hypertensive crisis. (Option D) Nausea, vomiting, and diarrhea are signs of acute gastroenteritis (ie, food poisoning). Most symptoms of food poisoning resolve spontaneously in several hours to days and are usually not life-threatening. Encouraging adequate oral hydration is important. Educational objective: The kidneys regulate fluid volume and blood pressure. Renal damage causes high blood pressure. Nausea, vomiting, and headache could be signs of a hypertensive crisis and require immediate further assessment.

Question 4

The nurse assesses a client with benign prostatic hyperplasia. Which client statement requires further assessment?

Accepted Answer

Benign prostatic hyperplasia (BPH) is an abnormal prostate enlargement that most commonly affects male clients age >50. The prostate gradually enlarges and compresses the urethra, causing voiding problems. Symptoms include urinary urgency, frequency, and hesitancy, dribbling urine after voiding, nighttime frequency (nocturia), and urinary retention. Treatment includes lifestyle changes and medications that shrink or slow growth of the prostate, and symptom management interventions (eg, voiding schedule, avoidance of caffeine and antihistamines). Surgical prostate resection may be required. Clients with BPH have increased risk for urinary tract infection (UTI) because of incomplete bladder emptying and urine retention. Symptoms of UTI are often similar to those of BPH; however, burning sensation with urination and cloudy/foul-smelling urine are specific UTI symptoms that require further assessment and treatment (Option A). (Options B and D) Dribbling after urination and nocturia are expected findings with BPH. (Option C) Finasteride (Proscar) is a medication that inhibits further growth of the prostate. Appreciable differences in prostate size are noticed only after several months of therapy. Missing three doses would not cause immediate or long-term adverse effects. Educational objective: Clients with benign prostatic hyperplasia (BPH) have increased risk for urinary tract infections (UTI) due to incomplete bladder emptying and urine retention. Symptoms of UTI that differ from those of BPH include burning sensation with urination and cloudy/foul-smelling urine.

Question 5

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? Select all that apply.

Accepted Answer

11ecbb05_ca8e_0bf3_b433_415cc7694747_MD0009_00 Overflow urinary incontinence occurs due to compression of the urethra (eg, uterine prolapse, prostate enlargement) or impairment of the bladder muscle (eg, spinal cord injury, diabetic neuropathy, anticholinergic medications). Both types involve incomplete bladder emptying and urinary retention, which lead to overdistension and overfilling of the bladder and frequent involuntary dribbling of urine. When caring for clients with overflow incontinence, the nurse should: Implement a fixed voiding schedule (eg, every 2 hours) to prevent bladder overfilling. Instruct the client to use the Valsalva maneuver (ie, "bearing down") and Credé maneuver (ie, gently applying pressure to the lower abdomen) to help facilitate bladder emptying (Option B). Assess the perineal area for skin breakdown related to incontinence (Option C). Measure postvoid residual volumes as prescribed to ensure that the client is not retaining large amounts of urine (Option D). Instruct the client to wait 20-30 seconds after voiding and then attempt to void a second time (ie, double voiding) to help empty residual urine (Option E). (Option A) Fluid restriction can lead to dehydration with concentrated urine, which irritates the bladder and increases the risk for urinary tract infection. Dehydration also contributes to constipation, which worsens incontinence by compressing the bladder. Educational objective: When caring for clients with overflow incontinence, the nurse should implement a fixed voiding schedule, teach the client techniques that assist with bladder emptying (eg, Valsalva maneuver, Credé maneuver, double voiding), monitor for perineal skin breakdown, and measure postvoid residual volumes as prescribed.

Question 6

A nurse is assessing a 58-year-old client with blurred vision and reduced visual fields. Which manifestation is of most concern to the nurse?

Accepted Answer

11ecbb05_ca90_7cf5_b433_b56c19faa8a0_MD0009_00 Acute angle-closure glaucoma is a form of glaucoma that requires immediate medical intervention. Glaucoma disorders are characterized by increased intraocular pressure (IOP) due to decreased outflow of the aqueous humor, resulting in compression of the optic nerve that can lead to permanent blindness. In acute angle-closure glaucoma, IOP increases rapidly and drastically, which can lead to the following manifestations: Sudden onset of severe eye pain Reduced central vision Blurred vision Ocular redness Report of seeing halos around lights (Options A and C) Gradual loss of peripheral vision and difficulty adjusting to different lighting are manifestations of chronic open-angle glaucoma. Although further evaluation and treatment are necessary, this condition develops slowly and is not considered an emergency situation. (Option D) Opaque lenses are characteristic of cataracts, which are not a medical emergency. Educational objective: Manifestations of acute angle-closure glaucoma include sudden onset of severe eye pain, reduced central vision, blurred vision, ocular redness, and report of seeing halos around lights. This condition requires immediate medical intervention to reduce IOP and prevent permanent blindness.

Question 7

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse?

Accepted Answer

Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. Option A indicates a retinal detachment requiring emergency management. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. An unrepaired complete retinal detachment can cause blindness. (Option B) The need for reading glasses is associated with presbyopia and is a common, nonemergency, age-related visual disorder. (Option C) Cloudy vision with a glare is associated with a cataract, a nonemergency, age-related visual disorder. (Option D) Although decreased vibrancy of colors is a sign of diabetic retinopathy and requires intervention, it is not indicative of a partial or complete retinal detachment; therefore, it is not an emergency. Educational objective: Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light.

Question 8

A 65-year-old client with end-stage renal disease comes to the emergency department after missing 5 hemodialysis sessions. Serum potassium level is 7.5 mEq/L (7.5 mmol/L) and ECG shows tall, peaked T waves. Which prescription will immediately protect the client from experiencing dysrhythmias associated with hyperkalemia?

Accepted Answer

11ecbb05_ca86_b8eb_b433_8b4c1ba15264_MD0009_00 Hyperkalemia can be asymptomatic but may cause fatigue, generalized weakness, or in severe cases muscle paralysis and/or dysrhythmias. Management includes preventing life-threatening dysrhythmias and correcting serum potassium levels. Intravenous calcium gluconate is administered to hyperkalemic clients with ECG changes (eg, peaked T waves). Calcium gluconate itself does not decrease the serum potassium level but temporarily stabilizes the myocardium by raising the threshold for dysrhythmia occurrence. Once the nurse stabilizes the client by administering calcium gluconate, other prescriptions may then be implemented to decrease serum potassium level (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) (Option A). (Option B) Intravenous regular insulin temporarily corrects hyperkalemia by shifting potassium into the cells. Dextrose is administered concurrently to prevent hypoglycemia. Although intravenous regular insulin will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. (Option C) Sodium polystyrene sulfonate causes excretion of potassium from the body via the gastrointestinal tract. Although this will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. (Option D) Although hemodialysis will effectively decrease serum potassium levels, calcium gluconate will provide immediate protection from dysrhythmias. Educational objective: The priority in treatment of hyperkalemia with ECG changes (eg, peaked T waves) is administration of intravenous calcium gluconate to prevent life-threatening dysrhythmias. Once calcium gluconate is administered, prescriptions to correct serum potassium (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) may be implemented.

Question 9

The nurse is caring for a client who received extracorporeal shock wave lithotripsy with ureteral stent placement for treatment of a kidney stone. Which discharge instructions provided by the nurse are appropriate? Select all that apply.

Accepted Answer

11ecbb05_ca8a_1450_b433_2334b9280553_MD0009_00 Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive procedure that uses high-energy acoustic shock waves to break up kidney stones into small fragments that can be excreted in the urine. The procedure is typically performed in an outpatient setting under general anesthesia. Temporary ureteral stents are often placed during the procedure to facilitate the passage of the stone fragments and prevent occlusion of the ureter. Stents are typically removed in 1-2 weeks. After an ESWL procedure, the client should be instructed to: Increase fluid intake to help flush out the kidney stone fragments (Option C). Expect some bruising and pain of the back and/or flank of the affected side. Analgesics may be required (Option E). Expect to see blood in the urine (hematuria). Urine color should progress from bright red to pink-tinged during the first several hours. Hematuria is concerning if the urine remains bright red for a prolonged period (eg, >24 hours) (Option D). Report any symptoms of infection (eg, fever, chills) to the health care provider (Option A). (Option B) Ambulation is encouraged after ESWL to facilitate passage of the stone fragments. Educational objective: Following extracorporeal shock wave lithotripsy, the client should increase fluid intake and ambulate frequently to facilitate passage of the stone fragments. Expected side effects include hematuria as well as bruising and pain of the back and/or flank. Urine color should progress from bright red to pink-tinged during the first several hours.

Question 10

Nausea and vomiting in which client is of greatest concern to the nurse?

Accepted Answer

11ecbb05_ca90_2ed4_b433_6db33fe278b8_MD0009_00 Increased intraocular pressure can cause damage to the blood vessels and retina and cause potential permanent vision loss. Coughing, vomiting, straining to lift objects (>5 lb), and bending at the waist temporarily increase intraocular pressure and must be avoided after eye surgery. Antiemetic medication is administered as needed following ophthalmic surgery to prevent vomiting. (Options B and D) Nausea and vomiting are expected side effects of chemotherapy and severe gastroenteritis. (Option C) Ménière disease affects the inner ear. Vertigo, nausea, and vomiting are expected manifestations of this disease. Educational objective: Vomiting can cause an increase in intraocular pressure, damage to the blood vessels and retina, and potential permanent vision loss. Antiemetic medication is administered as needed following ophthalmic surgery to prevent vomiting.

Question 11

A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?

Accepted Answer

11ecbb05_ca8b_9af1_b433_af53e6178d5f_MD0009_00 Arteriovenous fistula (AVF) is a permanent hemodialysis access surgically created by connecting an artery to a vein, typically in the forearm or upper arm. This anastomosis diverts arterial blood into the vein, which increases intravenous blood flow and causes the vein to thicken and expand (ie, "mature"). The matured AVF can then sustain frequent access by large-bore needles during hemodialysis. Arterial steal syndrome is an AVF complication that occurs when the anastomosed vein "steals" too much arterial blood, causing distal extremity ischemia. Symptoms occur distal to the AVF, including skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill. Without prompt intervention, ischemia may lead to limb necrosis (Option C). (Option A) After AVF creation, edema may occur due to venous congestion but typically improves spontaneously. Extremity elevation helps reduce edema. Severe or prolonged edema (eg, >2 weeks) could indicate venous hypertension that may require surgery to prevent AVF failure. (Option B) A loud swooshing sound (ie, bruit) auscultated over the AVF is expected due to turbulent blood flow at the arteriovenous anastomosis. (Option D) Hand-grip exercises (eg, ball squeezing, hand flexing) are encouraged after AVF creation to promote fistula maturation. Postoperative surgical site pain is expected; however, pain distal to the AVF may indicate tissue ischemia. Educational objective: Arterial steal syndrome is a complication of arteriovenous fistula (AVF) creation that impairs distal extremity perfusion and may result in tissue ischemia and necrosis. Symptoms include skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill distal to the AVF.

Question 12

A client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmol/L) and creatinine of 4.5 mg/dL (398 µmol/L). What is the priority prescribed intervention?

Accepted Answer

Severe hyperkalemia (potassium >7.0 mEq/L [7.0 mmol/L]) requires urgent treatment because cardiac muscle cannot tolerate very high potassium levels. Severe hyperkalemia increases the risk for life-threatening ventricular dysrhythmias (eg, ventricular tachycardia and fibrillation, asystole). IV administration of 50 mL 50% dextrose with 10 units of regular insulin is the priority intervention as it is most effective in reducing the potassium level quickly. The insulin temporarily shifts the potassium from the extracellular fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of insulin in the body and can be eliminated if the client has hyperglycemia (Option A). If the client has ECG changes (eg, tall peaked T waves), calcium gluconate should be given before insulin/dextrose. This will stabilize the cardiac muscle until the potassium level can be reduced with insulin/dextrose. (Option B) Furosemide (Lasix) increases the renal excretion of potassium and is usually prescribed for clients with fluid overload. However, administration of furosemide would take time to be effective and is not the priority. (Option C) Sodium polystyrene sulfonate (Kayexalate) is administered by mouth or enema to remove potassium from the body by exchanging sodium for potassium ions in the intestines; these are then excreted in feces. This is not the priority due to the delayed onset of potassium removal. (Option D) Hemodialysis is an invasive procedure that can be initiated if more conservative, noninvasive therapies are ineffective in reducing the potassium level. Placement of the catheter will delay treatment. Educational objective: Administration of IV 50% dextrose and regular insulin rapidly corrects an elevated serum potassium level by shifting potassium intracellularly. If the client has ECG changes from hyperkalemia, calcium gluconate should be given first to stabilize cardiac muscle.

Question 13

The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday. Which assessment finding would require immediate follow-up?

Accepted Answer

11ecbb05_ca88_3f8d_b433_71fa4c3bbc02_MD0009_00 An arteriovenous fistula is a surgical connection of an artery to a vein created to provide vascular access for hemodialysis therapy in clients with kidney disease. Arterial blood flowing through this vein causes it to engorge and thicken (mature) over a period of several weeks, after which it can sustain frequent access by 2 large-bore needles required for dialysis. Maturing of the fistula is aided by having the client perform hand exercises, such as squeezing a rubber ball, that increase blood flow through the vein. Following fistula placement, it is important to monitor for patency. A palpable thrill (vibration) over the fistula or an auscultated bruit (blowing or swooshing sound caused by turbulent blood flow) indicates a patent fistula. Absence of the thrill or bruit can indicate potential clot formation in the fistula. Client reports of numbness or tingling as well as decreased capillary refill can also signal potential clotting. (Option B) Capillary refill of <3 seconds is considered normal and indicates acceptable blood flow to the area. (Option C) Daily hand exercises such as squeezing handgrips or a rubber ball are performed to help properly mature the fistula. (Option D) A dry surgical incision without redness, warmth, and induration is an optimal finding. Sterile skin closures (eg, Steri-Strips) are used to help hold the incision together as it heals. Educational objective: Following placement of an arteriovenous fistula, it is imperative to monitor for signs of potential clotting of the fistula such as absence of a bruit, absence of a thrill, decreased capillary refill, and coolness of the extremity below the fistula.

Question 14

The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply.

Accepted Answer

11ecbb05_ca87_ca5c_b433_b1a76305194a_MD0009_00 Peritoneal dialysis uses the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with insufficient renal function. A catheter is placed into the peritoneal cavity, and dialysate (ie, dialysis fluid) is infused. The tubing is clamped to allow the fluid to remain in the cavity, usually for 20-30 minutes (dwell phase). The catheter is then unclamped to allow dialysate to drain via gravity. Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (eg, stool softeners) (Option A). The nurse should also check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation (Options C and E). The drainage bag should be maintained below the abdomen to promote gravity flow. The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics (eg, alteplase) as prescribed. If these measures are ineffective, an x-ray may be needed to check the catheter location. (Options B and D) The nurse should identify the problem before instilling additional fluids and perform routine assistive measures before contacting the health care provider. Educational objective: Insufficient outflow from peritoneal dialysis commonly results from constipation; bowel movements should be monitored and stool softeners administered as prescribed. Additional nursing measures include checking the tubing for kinks or clots; maintaining the drainage bag below the abdomen; and placing clients in a side-lying position or assisting with ambulation.

Question 15

A client returns to the unit after receiving hemodialysis for the first time. The client vomits once, reports headache, and appears restless and disoriented. What is the priority intervention?

Accepted Answer

Dialysis disequilibrium syndrome (DDS) is a rare but potentially life-threatening complication that can occur in clients during the initial stages of hemodialysis (HD); it can be prevented by slowing the rate of dialysis. During HD, solutes (ie, urea) are removed more quickly from the blood than from the brain cells and cerebrospinal fluid, creating a concentration gradient that can lead to excess fluid in the brain cells and increased intracranial pressure. Characteristic neurologic manifestations include nausea and vomiting, headache, restlessness, change in mentation, and seizure activity. If DDS is suspected, the health care provider should be contacted immediately (Option C). If severe, DDS can progress to coma and death. If DDS is identified during treatment, the rate of dialysis should be slowed or stopped. Treatment focuses on interventions to decrease cerebral edema and manage symptoms. (Option A) Antihypertensives are withheld prior to HD to minimize the risk for hypotension. If the client is not hypotensive after HD, prescribed antihypertensives should be administered but are not the priority intervention for a client with DDS. (Option B) Antiemetics should be administered to treat nausea associated with DDS, but they are not the priority intervention. (Option D) Trendelenburg position may increase cerebral edema and would be inappropriate for a client with DDS. Educational objective: Dialysis disequilibrium syndrome (DDS) is a potentially life-threatening condition associated with cerebral edema. Characteristic neurologic manifestations include nausea and vomiting, headache, restlessness, change in mentation, and seizure activity. If DDS is suspected, the health care provider should be contacted immediately and dialysis should be slowed or stopped.

Question 16

The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply.

Accepted Answer

11ecbb05_ca8c_fa82_b433_c95862a065e7_MD0009_00 Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate that is followed by urine leakage. UI may occur without cause or may result from spinal cord injury and impairment of the bladder (eg, interstitial cystitis) or neurological system (eg, Parkinson disease, stroke). Interventions for clients with UI include: Loss of excess weight to reduce pressure on the pelvic floor (Option A). Anticholinergic medications (eg, oxybutynin, tolterodine) to decrease bladder spasms. Dry mouth (xerostomia) is a frequent adverse effect (Option B). Avoidance of bladder irritants (eg, artificial sweeteners, caffeine, citrus juices, alcohol, carbonated drinks, nicotine) (Option C). Pelvic floor exercises (eg, Kegel) to strengthen the muscles and help prevent urinary leakage (Option D). Bladder training (eg, voiding every 2 hours while awake) and gradually lengthening intervals between voiding (Option E). Educational objective: Management of urge incontinence includes loss of excess weight, anticholinergic medications (eg, oxybutynin), avoidance of bladder irritants, pelvic floor exercises, and bladder training. Dry mouth is a common adverse effect of anticholinergic medications.

Question 17

The nurse is caring for a client with multiple renal calculi. Which nursing interventions should be included in the plan of care? Select all that apply.

Accepted Answer

The formation of renal calculi (ie, kidney stones) can be due to various factors (eg, family history, dietary imbalances, immobilization, dehydration). Manifestations include sudden, severe abdominal or flank pain and nausea/vomiting. Client management focuses on analgesics administered at regularly scheduled intervals, rehydration of up to 3 L/day unless contraindicated by other comorbidities, and ambulation to facilitate the passage of calculi (Options A and B). To retrieve stones that the client may pass, the nurse should strain all urine obtained (Option E). The collected stones are analyzed to determine their composition (eg, calcium oxalate, calcium phosphate, struvite, uric acid, cystine), which can then direct preventive measures, such as dietary and lifestyle changes, after discharge. (Option C) Immobilization is a contributing cause of renal calculi formation and should be avoided. Ambulation and frequent mobilization are encouraged as tolerated to help facilitate the passage of calculi. (Option D) Massage therapy to the flank should not be performed to prevent further instigation of renal colic. Other interventions, such as monitored heat therapy, would be acceptable. Educational objective: When caring for a client with renal calculi, the nurse should provide adequate analgesia for pain, encourage increased fluid intake, and assist with ambulation as tolerated to promote clearance of calculi. All urine should be strained to retrieve any stones for analysis to determine preventive measures.

Question 18

A client had a percutaneous nephrolithotripsy 3 hours ago to remove left renal calculi.  Since then, the indwelling urethral catheter has drained 125 mL of urine and the nephrostomy tube has drained 0 mL.  The client now reports left flank pain radiating to the left groin along with severe nausea.  What is the appropriate nursing intervention?

Accepted Answer

11ecbb05_ca86_1caa_b433_0b527171f863_MD0009_00 Percutaneous nephrolithotripsy involves the insertion of a needle and sheath through the skin into the pelvis of the kidney. A nephroscope is inserted through the sheath to break and remove kidney stones too large to remove with other methods. Post procedure, a temporary percutaneous nephrostomy tube may be placed to prevent obstruction by stone fragments and to promote healing of injured tissue; maintaining tube patency is critical. This client is experiencing left flank pain and has no drainage from the nephrostomy tube, which may indicate obstruction to urine flow in the left kidney that can lead to kidney injury (pressure atrophy). Gentle irrigation of the nephrostomy tube with a small volume of sterile normal saline (as prescribed or per protocol) using aseptic technique is the appropriate intervention. If tube patency cannot be established after irrigation, the health care provider is notified (Option B). (Options A and C) The indwelling urethral catheter is appropriately draining 42 mL/hr, so it is not likely kinked or obstructed. The urine flow is likely coming from a normal-functioning right kidney. (Option D) The client is placed in the prone position for the procedure, but this does not facilitate drainage. Educational objective: A percutaneous nephrolithotripsy is a procedure to remove large kidney stones from the renal pelvis. Post procedure, a nephrostomy tube may be placed to prevent obstruction by stone fragments and to promote healing of injured tissue. Gentle irrigation of the nephrostomy tube with sterile normal saline may be necessary to maintain tube patency.

Question 19

The nurse prepares to instill dialysate for a client receiving peritoneal dialysis. Which nursing action is the priority?

Accepted Answer

11ecbb05_ca89_29ee_b433_b19788a80b21_MD0009_00 In peritoneal dialysis (PD), the abdominal lining (peritoneum) is used as a semipermeable membrane to dialyze clients with decreased kidney function. A catheter is placed in the peritoneal cavity for infusing and draining dialysate (dialysis fluid). Dialysate is infused and dwells in the abdomen, which allows waste products and electrolytes to cross the peritoneum into the dialysate for removal. After the prescribed dwell time, the dialysate, electrolytes, and wastes are drained via gravity. When administering PD, it is essential to use sterile technique when spiking and attaching bags of dialysate to the client's PD catheter to prevent contamination and infection (Option D). Bacterial peritonitis, an infection of the peritoneum, is a potential complication of PD that may lead to sepsis. Signs of peritonitis should be reported to the health care provider. (Options A and B) Proper positioning of the catheter drainage bag (ie, below the abdomen) and the client (eg, Fowler or semi-Fowler position) promotes effluent outflow but is not a priority over infection prevention. (Option C) Cloudy effluent may indicate infection, whereas bloody or brown effluent may indicate bowel perforation. Documenting effluent characteristics is important but not a priority over maintaining asepsis. Educational objective: Peritoneal dialysis (PD) uses the peritoneum as a semipermeable membrane to dialyze clients with decreased kidney function. Bacterial peritonitis is a potential complication of PD. Using sterile technique when spiking or changing bags of dialysate is a priority to avoid contamination and reduce the risk of peritonitis.

Question 20

The nurse assesses a client receiving peritoneal dialysis. Which assessment findings are most important for the nurse to report to the health care provider? Select all that apply.

Accepted Answer

11ecbb05_ca89_9f1f_b433_3b89dc3e5210_MD0009_00 During peritoneal dialysis (PD), a catheter is placed into the peritoneal cavity to infuse dialysate (dialysis fluid); the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid (effluent) drains out via gravity. Cloudy outflow (effluent), tachycardia, and low-grade fever are signs of peritonitis, an infection of the peritoneal cavity and a major concern with PD. Bloody fluid can indicate intestinal perforation or that the client may be menstruating. Brown effluent can indicate fecal contamination from perforation. All these findings need to be reported to the health care provider. (Option C) Oliguria (very low urine output) is associated with acute or chronic kidney failure and is the reason the client is receiving peritoneal dialysis. It does not indicate a complication of PD. (Option D) Pruritus (itching) is a common finding in clients with kidney failure, and may occur due to dry skin, neuropathy, or skin deposits of waste products (eg, urea, calcium-phosphate) that are normally removed via the kidney. PD can help relieve this symptom of kidney failure by filtering waste products. Educational objective: Peritonitis is a major complication of peritoneal dialysis. Signs of developing peritonitis are low-grade fever, tachycardia, and cloudy outflow (effluent). Bloody effluent can indicate intestinal perforation or that the client may be menstruating.

Exam 1: Adult Health

The nurse assesses a client during the dwell time of a peritoneal dialysis cycle. Which assessment would require immediate intervention?

A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye. The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation. What action is appropriate at this time?

A clinic nurse receives messages on 4 clients. Which client should the nurse call back first?

The nurse assesses a client with benign prostatic hyperplasia. Which client statement requires further assessment?

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? Select all that apply.

A nurse is assessing a 58-year-old client with blurred vision and reduced visual fields. Which manifestation is of most concern to the nurse?

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse?

The nurse is caring for a client who received extracorporeal shock wave lithotripsy with ureteral stent placement for treatment of a kidney stone. Which discharge instructions provided by the nurse are appropriate? Select all that apply.

Nausea and vomiting in which client is of greatest concern to the nurse?

A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?

A client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmol/L) and creatinine of 4.5 mg/dL (398 µmol/L) . What is the priority prescribed intervention?

The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday. Which assessment finding would require immediate follow-up?

The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply.

A client returns to the unit after receiving hemodialysis for the first time. The client vomits once, reports headache, and appears restless and disoriented. What is the priority intervention?

The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply.

The nurse is caring for a client with multiple renal calculi. Which nursing interventions should be included in the plan of care? Select all that apply.

The nurse prepares to instill dialysate for a client receiving peritoneal dialysis. Which nursing action is the priority?

The nurse assesses a client receiving peritoneal dialysis. Which assessment findings are most important for the nurse to report to the health care provider? Select all that apply.