Preview Extract
Chapter 47
1. A chronic renal failure client is exhibiting signs of metabolic acidosis. Upon assessment of the client’s respiratory status, the nurse would expect:
1. Kussmaul respirations.
2. Periods of apnea.
3. Dyspnea.
4. Cheyne-Stokes respirations.
Answer: Kussmaul respirations.
Rationale:
Kussmaul respirations are the body’s physiologic response to acidosis. The client will exhibit Kussmaul respirations in attempt to blow off excess CO2. Periods of apnea is incorrect because the client will not be able to get rid of excess hydrogen ions if he or she is having periods of apnea. The patient should exhibit rapid deep respirations, not difficulty with breathing. Cheyne-Stokes respirations are exhibited with metabolic alkalosis.
2. Which of the following nursing diagnoses would the nurse expect for a client with a decreased erythropoietin production?
1. Risk for Injury
2. Risk for Fluid-Volume Deficit
3. Risk for Infection
4. Risk for Altered Nutrition
Answer: Risk for Injury
Rationale:
When the kidneys are not producing erythropoietin, the client will have a decrease in red blood cell production. With a low red blood cell production, the client will exhibit signs of anemia, and will therefore be at risk for injury from fatigue and weakness. Risk for Fluid-Volume Deficit is incorrect because the client is not going to have a fluid shift with a decreased red blood cell production. The patient would not be at increased risk for infection because the decreased erythropoietin production indicates a decrease in red blood cell production, not white blood cell production. Nutritional status is not directly impacted by the decreased red blood cell production.
3. A client admitted with an infection of the urinary tract is experiencing hypotension and shock. The nurse understands that the physiologic response of the kidneys during this state would reveal an increase in:
Select all that apply.
1. Renin.
2. Antidiuretic hormone .
3. Aldosterone.
4. Vitamin D.
5. Chloride.
Answer: 1. Renin.
2. Antidiuretic hormone .
3. Aldosterone.
Rationale:
Renin. There will be an increase in the secretion of renin, which converts angiotensinogen to angiotensin, stimulating the release of aldosterone by the adrenal cortex. Antidiuretic hormone. There will be an increase in the antidiuretic hormone in response to an increased serum osmolality. Aldosterone. There will be an increase in the secretion of rennin, which converts angiotensinogen to angiotensin, stimulating the release of aldosterone by the adrenal cortex. Vitamin D. This does not reflect hydration status, which is normally impaired in hypotension and shock states. Chloride. This level is not increased in shock states.
4. A client is admitted with acute glomerulonephritis. The nurse inspects the client’s urine and expects to find:
1. Tea-colored urine.
2. Orange-colored urine.
3. Clear yellow urine.
4. Green-colored urine.
Answer: Tea-colored urine.
Rationale:
The client will exhibit hematuria, or blood in the urine, and the urine will have a tea-colored appearance. Orange-colored urine is associated with the use of antibiotics or chemotherapy drugs. Clear yellow urine is a normal finding in a urinalysis. Green-colored urine would indicate disorders associated with high calcium levels.
5. The nurse is preparing to administer antibiotics to a client with pyelonephritis. The nurse understands that the implementation of this order was based on the results of the client’s:
1. Urine culture.
2. Urinalysis.
3. X-ray films of the kidneys.
4. Intravenous pyleogram.
Answer: Urine culture.
Rationale:
The urine culture would identify the organism causing the infection of the kidney. A urinalysis does not identify the type of bacteria present in the kidney. X-ray films of the kidney would not identify the type of organism causing the infection of the kidney. An intravenous pyleogram involves the injection of a dye into the bloodstream, which concentrates in the urinary tract to better visualize the structures of the urinary tract.
6. A client is diagnosed with acute tubular necrosis. The nurse understands that cardiac monitoring would be indicated based on which laboratory findings?
Select all that apply:
1. Hyperkalemia
2. Hypercalcemia
3. Hyperphosphatemia
4. Lymphocytosis
5. Leukocytosis
Answer: 1. Hyperkalemia
2. Hypercalcemia
3. Hyperphosphatemia
Rationale:
Hyperkalemia. The kidneys have lost their ability to regulate electrolyte excretion; hyperkalcemia levels can quickly change with acute tubular necrosis and result in cardiac complications. Therefore, it is necessary that the client have EKG monitoring continuously to identify changes in the client’s condition. Hypercalcemia. The kidneys have lost their ability to regulate electrolyte excretion; hypercalcemia levels can quickly change with acute tubular necrosis and result in cardiac complications. Therefore, it is necessary that the client have EKG monitoring continuously to identify changes in the client’s condition. Hyperphosphatemia. The kidneys have lost their ability to regulate electrolyte excretion; hyperphosphatemia levels can quickly change with acute tubular necrosis and result in cardiac complications. Therefore, it is necessary that the client have EKG monitoring continuously to identify changes in the client’s condition. Lymphocytosis. Lymphocytes are not affected in acute tubular necrosis. Leukocytosis. Leukocytosis would only be elevated if the client had an infection. In this case, the client does not.
7. Which of the following nursing diagnoses would the nurse incorporate in the plan of care of a newly diagnosed client with polycystic disease?
Select all that apply.
1. Alteration in Comfort
2. Ineffective Coping
3. Risk for Impaired Mobility
4. Impaired Skin Integrity
5. Impaired Gas Exchange
Answer: 1. Alteration in Comfort
2. Ineffective Coping
3. Risk for Impaired Mobility
Rationale:
Alteration in comfort. The client with polycystic disease will experience abdominal and lumbar pain. Ineffective coping. Half of children born to a client with polycystic disease will have the disease, which is also progressive. Risk for impaired mobility. The pain of polycystic disease may decrease the client’s ability to ambulate. Impaired skin integrity. The skin is not affected with this disease. Impaired gas exchange. The respiratory system is not involved with a newly diagnosed client.
8. A client is concerned about the risk of developing renal carcinoma. The nurse should respond by asking which of the following questions that would indicate the client may be at increased risk of developing of renal carcinoma?
1. “Do you smoke cigarettes?”
2. “Do you exercise regularly?”
3. “Are you taking any medications?”
4. “Do you take herbal supplements?”
Answer: “Do you smoke cigarettes?”
Rationale:
Environmental carcinogens such as tobacco have been found to predispose a person to transitional cell tumors such as with renal carcinoma. Exercising regularly may prevent renal carcinoma. There are no known medications that contribute to the disease. The use of herbal supplements has not been proven to cause renal cancer.
9. The nurse is caring for a client with an elevated serum blood urea nitrogen (BUN) and creatinine. The client is scheduled for a CT scan with contrast. The nurse would:
1. Notify the health care provider to withhold contrast.
2. Monitor blood pressure before and after the procedure.
3. Hydrate well prior to the procedure.
4. Keep the client NPO after the procedure.
Answer: Notify the health care provider to withhold contrast.
Rationale:
The nurse should notify the health care provider to withhold contrast because a client with an elevated BUN and creatinine indicates impaired renal function. With an impaired renal function, the client would not be able to readily excrete the contrast media. This may lead to an intrarenal cause of acute renal failure. Blood pressure would not be influenced by the administration of the contrast media. With the renal impairment of the client, hydration would not decrease the risk of the client developing acute renal failure.
10. A peritioneal dialysis client states that during the home exchanges, the return solution is cloudy. The nurse would respond by asking the client:
Select all that apply.
1. “Do you wash your hands prior to the exchanges?”
2. “How do you change your dialysis catheter dressing?”
3. “Have you developed any recent fevers?”
4. “What color is your urine?”
5. “At what time of the day do you perform your exchanges?”
Answer: 1. “Do you wash your hands prior to the exchanges?”
2. “How do you change your dialysis catheter dressing?”
3. “Have you developed any recent fevers?”
Rationale:
“Do you wash your hands prior to the exchanges?” The client has peritonitis, as evidenced by the cloudy return dialysate; the questioning of aseptic techniques is necessary to determine the cause of the peritonitis. “How do you change your dialysis catheter dressing?” The client has peritonitis, as evidenced by the cloudy return dialysate; the questioning of aseptic techniques is necessary to determine the cause of the peritonitis. “Have you developed any recent fevers?” Fevers would further indicate that the client has developed peritonitis. “What color is your urine?” The client is in chronic renal failure and will be anuric. “At what time of the day do you perform your exchanges?” The time of the day of exchanges does not influence the risk of peritonitis.
11. The nurse caring for a client with acute renal failure realizes that a complication has occurred during the diuretic stage of the disorder when the client exhibits signs of:
Select all that apply.
1. Hypovolemia.
2. Hypotension.
3. Infection.
4. Hyperkalemia.
5. Hypernatremia.
Answer: 1. Hypovolemia.
2. Hypotension.
3. Infection.
Rationale:
Hypovolemia. The client will have large amounts of urine output, as high as 1 to 2 liters/day. This places the client at risk for hypovolemia. Hypotension. The client will have large amounts of urine output, as high as 1to 2 liters/day. This places the client at risk for hypotension. Infection. The client can exhibit signs of infection during any phase of acute renal failure. Hyperkalemia. The client will exhibit signs of hypokalemia with the excessive amounts of urine output. Hypernatremia. The sodium level would decrease in this phase.
12. The nurse caring for a chronic renal failure client notes that the client’s oral mucosa is dry and cracked. The nurse would:
Select all that apply.
1. Provide frequent oral care.
2. Offer hard candy.
3. Document the finding.
4. Encourage fluids.
5. Administer a fluid bolus.
Answer: 1. Provide frequent oral care.
2. Offer hard candy.
3. Document the finding.
Rationale:
Provide frequent oral care. Provide frequent oral care to decrease the dryness of the oral mucosa, remove debris, and add comfort. Offer hard candy. Hard candy should be offered because this will stimulate salivation, adding to the comfort of the client. Document the finding. The nurse should document this finding to alert other staff of the condition of the oral mucosa and measures implemented to increase client comfort. Encourage fluids. Chronic renal failure clients are fluid restricted. Administer a fluid bolus. Administering a fluid bolus would not be indicated because of the fluid restriction of chronic renal failure clients.
13. A client admitted with nephrolithiasis complains of flank pain. The nurse understands that the client’s stone is most likely located in the renal pelvis and calyces because the client describes the nature of the pain as:
Select all that apply:
1. Dull.
2. Constant.
3. Severe.
4. Colicky.
5. Intermittent.
Answer: 1. Dull.
2. Constant.
Rationale:
Dull. The pain would be dull and constant because the calculi are located in the renal pelvis, which is larger anatomically than the ureter, causing severe pain. Constant. The pain would be constant because the calculi are located in the renal pelvis, which is a larger anatomically than the ureter, causing severe pain. Severe. The pain would be severe and colicky as it travels from the costovertebral angle to the flank. Colicky. The pain would be severe and colicky as it travels from the costovertebral angle to the flank. Intermittent. The pain is constant when the stone is in the renal pelvis.
14. A client with cystitis is being treated with phenazopyridine hydrochloride (pyridium). The client notifies the nurse upon voiding because of the bright orange color of the urine. The nurse would:
1. Reassure the client that this is expected.
2. Check the clarity of the urine.
3. Strain and reexamine the urine.
4. Encourage the client to drink fluids.
Answer: Reassure the client that this is expected.
Rationale:
The nurse should reassure the client that this is expected with this medication. The color is normal with this medication. The urine may be cloudy; however, this is expected with a diagnosis of cystitis. Straining and examining the urine would be implemented for a client with urinary calculi. Encouraging the client to drink fluids is indicated for a client with cystitis, but this will not change the side effect of the orange-colored urine.
15. A client with a nephrostomy tube complains of pain and pressure at the site. The nurse would:
1. Assess for obstruction.
2. Irrigate the tube.
3. Clamp the tube.
4. Administer pain medication.
Answer: Assess for obstruction.
Rationale:
The nurse should assess for obstruction of the tube because these signs and symptoms are related to nephrostomy tube obstruction. Irrigation of the tube is contraindicated unless ordered by the health care provider. Clamping the tube would further cause urine backflow and retention, which may lead to infection because of the stasis of urine. Administering pain medication will not resolve the cause of the tube obstruction.
16. The nurse is caring for a client with an AV fistula. Upon assessment the nurse notes that the extremity with the fistula is pale and cool. The nurse would initially:
1. Auscultate the fistula.
2. Notify the health care provider.
3. Check vital signs.
4. Document the finding.
Answer: Auscultate the fistula.
Rationale:
Auscultating the fistula would allow the nurse to determine the presence of a bruit, which would indicate adequate blood flow through the fistula. The nurse would gather further assessment data prior to notifying the health care provider. Checking vital signs would not determine if the fistula was patent. Documenting the finding would not assist in determining the patency of the fistula.
17. The nurse is caring for a chronic renal failure client with an AV fistula. The client has just completed hemodialysis. Site care of the fistula would initially involve:
1. Application of firm pressure to the site.
2. Placing a sterile dressing over the site.
3. Checking the blood pressure in the extremity.
4. Applying antibiotic ointment to the site.
Answer: Application of firm pressure to the site.
Rationale:
After the discontinuation of the dialysis needles that were placed into the artery and vein of the fistula, the client would be at risk for bleeding; firm pressure at the site should be applied until bleeding has stopped. The fistula will not require a dressing after the completion of hemodialysis. A blood pressure obtained in the extremity of the fistula could occlude the fistula. There is no need to apply antibiotic ointment to the site unless there are signs of infection present.
18. The nurse is caring for a client receiving hemodialysis. Which of the following assessments would be necessary to detect complications of disequilibrium syndrome?
1. Level of consciousness
2. Fluid intake
3. Temperature
4. Urine output
Answer: Level of consciousness
Rationale:
With the removal of solutes in the blood more rapidly than from cerebrospinal fluid and the brain, changes in level of consciousness would be seen. Intake and output would not reflect a sign indicating disequilibrium syndrome. Monitoring temperature would indicate the possibility of infection, not disequilibrium syndrome. Monitoring urine output does not indicate a sign of disequilibrium syndrome.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
