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Nur 352 Exam 3 Ch 48

Terms in this set (40)

1. The nurse is assessing a patient suspected of having developed acute
glomerulonephritis. The nurse should expect to address what clinical manifestation
that is characteristic of this health problem?
A) Hematuria
B) Precipitous decrease in serum creatinine levels
C) Hypotension unresolved by fluid administration
D) Glucosuria
Ans: A
Feedback:
The primary presenting feature of acute glomerulonephritis is hematuria(blood in
the urine), which may be microscopic (identifiable through microscopic
examination) or macroscopic or gross (visible to the eye). Proteinuria, primarily
albumin, which is present, is due to increased permeability of the glomerular
membrane. Blood urea nitrogen (BUN) and serum creatinine levels may rise as urine
output drops. Some degree of edemaand hypertension is noted in most patients.
2. The nurse is caring for acutely ill patient. What assessment finding should prompt
the nurse to inform the physician that the patient may be exhibiting signs of acute
kidney injury (AKI)?
A) The patient is complains of an inability to initiate voiding.
B) The patients urine is cloudy with afoul odor.
C) The patients average urine output has been 10 mL/hr for several hours.
D) The patient complains of acute flank pain.
Ans: C
Feedback:
Oliguria(<500 mL/d of urine) is the most common clinical situation seen in AKI.
Flank pain and inability to initiate voiding are not characteristic of AKI. Cloudy,
foul-smelling urine is suggestive of a urinary tract infection.
3. The nurse is caring for a patient with a history of systemic lupus erythematosus who
has been recently diagnosed with end-stage kidney disease (ESKD). The patient has
an elevated phosphorus level and has been prescribed calcium acetate to bind the
phosphorus. The nurse should teach the patient to take the prescribed phosphorusbinding medication at what time?
A) Only when needed
B) Daily at bedtime
C) First thing in the morning
D) With each meal
Ans: D
Feedback:
Both calcium carbonate and calcium acetate are medications that bind with the
phosphate and assist in excreting the phosphate from the body, in turn lowering the
phosphate levels. Phosphate-binding medications must be administered with food to
be effective.
4. The nurse is working on the renal transplant unit. To reduce the risk of infection in a
patient with atransplanted kidney, it is imperative for the nurse to do what?
A) Wash hands carefully and frequently.
B) Ensure immediate function of the donated kidney.
C) Instruct the patient to wear aface mask.
D) Bar visitors from the patients room.
Ans: A
Feedback:
The nurse ensures that the patient is protected from exposure to infection by hospital
staff, visitors,and other patients with active infections. Careful handwashing is
imperative; face masks may be worn by hospital staff and visitors to reduce the risk
for transmitting infectious agents while the patient is receiving high doses of
immunosuppressants. Visitors may be limited, but are not normally barred outright.
Ensuring kidney function is vital, but does not prevent infection.
5. The nurse is caring for a patient receiving hemodialysis three times weekly. The
patient has had surgery to form an arteriovenous fistula. What is most important for
the nurse to be aware of when providing care for this patient?
A) Using astethoscope for auscultating the fistulais contraindicated.
B) The patient feels best immediately after the dialysis treatment.
C) Taking a BP reading on the affected arm can damage the fistula.
D) The patient should not feel pain during initiation of dialysis.
Ans: C
Feedback:
When blood flowis reduced through the access for any reason (hypotension,
application of BP cuff/tourniquet), the access site can clot. Auscultation of a bruit in
the fistulais one way to determine patency. Typically, patients feel fatigued
immediately after hemodialysis because of the rapid change in fluid and electrolyte
status. Although the area over the fistula may have some decreased sensation,a
needle stick is still painful.
6. A patient has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2
. Based on this
GFR, the nurse interprets that the patients chronic kidney disease is at what stage?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Ans: C
Feedback:
Stages of chronic renal failure are based on the GFR. Stage 3 is defined by a GFR in
the range of 30 to 59 mL/min/1.73 m2
. This is considered a moderate decrease in
GFR.
7. Afootball player is thought to have sustained an injury to his kidneys from being
tackled from behind. The ER nurse caring for the patient reviews the initial orders
written by the physician and notes that an order to collect all voided urine and send
it to the laboratory for analysis. The nurse understands that this nursing intervention
is important for what reason?
A) Hematuriais the most common manifestation of renal traumaand blood losses
may be microscopic, so laboratory analysis is essential.
B) Intake and output calculations are essential and the laboratory will calculate the
precise urine output produced by this patient.
C) Acreatinine clearance study may be ordered at alater time and the laboratory
will hold all urine until it is determined if the test will be necessary.
D) There is great concern about electrolyte imbalances and the laboratory will
monitor the urine for changes in potassium and sodium concentrations.
Ans: A
Feedback:
Hematuriais the most common manifestation of renal trauma; its presence after
traumasuggests renal injury. Hematuria may not occur, or it may be detectable only
on microscopic examination. All urine should be saved and sent to the laboratory
for analysis to detect RBCs and to evaluate the course of bleeding. Measuring
intake and output is not afunction of the laboratory. The laboratory does not save
urine to test creatinine clearance at alater time. The laboratory does not monitor
the urine for sodium or potassium concentrations.
8. A patient admitted with nephrotic syndrome is being cared for on the medical unit.
When writing this patients care plan, based on the major clinical manifestation of
nephrotic syndrome, what nursing diagnosis should the nurse include?
A) Constipation related to immobility
B) Risk for injury related to altered thought processes
C) Hyperthermiarelated to the inflammatory process
D) Excess fluid volume related to generalized edema
Ans: D
Feedback:
The major clinical manifestation of nephrotic syndrome is edema, so the appropriate
nursing diagnosis is Excess fluid volume related to generalized edema. Edemais
usually soft, pitting,and commonly occurs around the eyes, in dependent areas,and
in the abdomen.
9. The nurse coming on shift on the medical unit is taking areport on four patients.
What patient does the nurse knowis at the greatest risk of developing ESKD?
A) A patient with a history of polycystic kidney disease
B) A patient with diabetes mellitus and poorly controlled hypertension
C) A patient who is morbidly obese with a history of vascular disorders
D) A patient with severe chronic obstructive pulmonary disease
Ans: B
Feedback:
Systemic diseases, such as diabetes mellitus (leading cause); hypertension;chronic
glomerulonephritis; pyelonephritis; obstruction of the urinary tract; hereditary
lesions, such as in polycystic kidney disease; vascular disorders; infections;
medications; or toxic agents may cause ESKD. A patient with more than one of these
risk factors is at the greatest risk for developing ESKD. Therefore, the patient with
diabetes and hypertension is likely at highest risk for ESKD.
10. The nurse is caring for a patient postoperative day 4 following a kidney transplant.
When assessing for potential signs and symptoms of rejection, what assessment
should the nurse prioritize?
A) Assessment of the quantity of the patients urine output
B) Assessment of the patients incision
C) Assessment of the patients abdominal girth
D) Assessment for flank or abdominal pain
Ans: A
Feedback:
After kidney transplantation, the nurse should perform all of the listed assessments.
However, oliguriais considered to be more suggestive of rejection than changes to
the patients abdomen or incision.
11. The nurse is caring for a patient in acute kidney injury. Which of the following
complications would most clearly warrant the administration of polystyrene
sulfonate (Kayexalate)?
A) Hypernatremia
B) Hypomagnesemia
C) Hyperkalemia
D) Hypercalcemia
Ans: C
Feedback:
Hyperkalemia,acommon complication of acute kidney injury, is life-threatening if
immediate action is not taken to reverse it. The administration of polystyrene
sulfonate reduces serum potassium levels.
12. Renal failure can have prerenal, renal, or postrenal causes. A patient with acute
kidney injury is being assessed to determine where, physiologically, the cause is. If
the cause is found to be prerenal, which condition most likely caused it?
A) Heart failure
B) Glomerulonephritis
C) Ureterolithiasis
D) Aminoglycoside toxicity
Ans: A
Feedback:
By causing inadequate renal perfusion, heart failure can lead to prerenal failure.
Glomerulonephritis and aminoglycoside toxicity are renal causes,and
ureterolithiasis is a postrenal cause.
13. A45-year-old man with diabetic nephropathy has ESKD and is starting dialysis.
What should the nurse teach the patient about hemodialysis?
A) Hemodialysis is atreatment option that is usually required three times a week.
B) Hemodialysis is a program that will require you to commit to daily treatment.
C) This will require you to have surgery and acatheter will need to be inserted into
your abdomen.
D) Hemodialysis is atreatment that is used for afewmonths until your kidney
heals and starts to produce urine again.
Ans: A
Feedback:
Hemodialysis is the most commonly used method of dialysis. Patients receiving
hemodialysis must undergo treatment for the rest of their lives or until they
undergo successful kidney transplantation. Treatments usually occur three times a
week for at least 3 to 4 hours per treatment.
14. A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse
observes that the dialysate drainage fluid is cloudy. What is the nurses most
appropriate action?
A) Inform the physician and assess the patient for signs of infection.
B) Flush the peritoneal catheter with normal saline.
C) Remove the catheter promptly and have the catheter tip cultured.
D) Administer a bolus of IVnormal saline as ordered.
Ans: A
Feedback:

Peritonitis is the most common and serious complication of peritoneal dialysis. The
first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the
primary care provider and rapid assessment for other signs of infection are
warranted. Administration of an IVbolus is not necessary or appropriate and the
physician would determine whether removal of the catheter is required. Flushing the
catheter does not address the risk for infection.
15. The nurse is planning patient teaching for a patient with ESKD who is scheduled for
the creation of afistula. The nurse would include which of the following in teaching
the patient about the fistula?
A) Avein and an artery in your arm will be attached surgically.
B) The arm should be immobilized for 4 to 6 days.
C) One needle will be inserted into the fistulafor each dialysis treatment.
D) The fistulacan be used 2 days after the surgery for dialysis treatment.
Ans: A
Feedback:
The fistulajoins an artery and a vein,either side-to-side or end-to-end. This access
will need time, usually 2 to 3 months, to mature before it can be used. The patient is
encouraged to perform exercises to increase the size of the affected vessels (e.g.,
squeezing arubber ball for forearm fistulas). Two needles will be inserted into the
fistulafor each dialysis treatment.
16. A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with
the patient to adapt the patients diet to maximize the therapeutic effect and minimize
the risks of complications. The patients diet should include which of the following
modifications? Select all that apply.
A) Decreased protein intake
B) Decreased sodium intake
C) Increased potassium intake
D) Fluid restriction
E) Vitamin D supplementation
Ans: A, B, D
Feedback:
Restricting dietary protein decreases the accumulation of nitrogenous wastes,
reduces uremic symptoms,and may even postpone the initiation of dialysis for afew
months. Restriction of fluid is also part of the dietary prescription because fluid
accumulation may occur. As well, sodium is usually restricted to 2 to 3 g/day.
Potassium intake is usually limited, not increased,and there is no particular need for
vitamin D supplementation.
17. A patient on the critical care unit is postoperative day 1 following kidney
transplantation from aliving donor. The nurses most recent assessments indicate
that the patient is producing copious quantities of dilute urine. What is the nurses
most appropriate response?
A) Assess the patient for further signs or symptoms of rejection.
B) Recognize this as an expected finding.
C) Inform the primary care provider of this finding.
D) Administer exogenous antidiuretic hormone as ordered.
Ans: B
Feedback:
Akidney from aliving donor related to the patient usually begins to function
immediately after surgery and may produce large quantities of dilute urine. This is
not suggestive of rejection and treatment is not warranted. There is no obvious need
to report this finding.
18. A patient is scheduled for a CT scan of the abdomen with contrast. The patient has a
baseline creatinine level of 2.3 mg/dL. In preparing this patient for the procedure,
the nurse anticipates what orders?
A) Monitor the patients electrolyte values every hour before the procedure.
B) Preprocedure hydration and administration of acetylcysteine
C) Hemodialysis immediately prior to the CT scan
D) Obtain acreatinine clearance by collecting a 24-hour urine specimen.
Ans: B
Feedback:

Radiocontrast-induced nephropathy is a major cause of hospital-acquired acute
kidney injury. Baseline levels of creatinine greater than 2 mg/dL identify the patient
as being high risk. Preprocedure hydration and prescription of acetylcysteine
(Mucomyst) the day prior to the test is effective in prevention. The nurse would not
monitor the patients electrolytes every hour preprocedure. Nothing in the scenario
indicates the need for hemodialysis. Acreatinine clearance is not necessary prior to
a CT scan with contrast.
19. The nurse is caring for a patient with acute glomerular inflammation. When
assessing for the characteristic signs and symptoms of this health problem, the
nurse should include which assessments? Select all that apply.
A) Percuss for pain in the right lower abdominal quadrant.
B) Assess for the presence of peripheral edema.
C) Auscultate the patients apical heart rate for dysrhythmias.
D) Assess the patients BP.
E) Assess the patients orientation and judgment.
Ans: B, D
Feedback:
Most patients with acute glomerular inflammation have some degree of edemaand
hypertension. Dysrhythmias, RLQ pain,and changes in mental status are not among
the most common manifestations of acute glomerular inflammation.
20. A patient is admitted to the ICU after a motor vehicle accident. On the second day of
the hospital admission, the patient develops acute kidney injury. The patient is
hemodynamically unstable, but renal replacement therapy is needed to manage the
patients hypervolemiaand hyperkalemia. Which of the following therapies will the
patients hemodynamic status best tolerate?
A) Hemodialysis
B) Peritoneal dialysis
C) Continuous venovenous hemodialysis (CVVHD)
D) Plasmapheresis
Ans: C
Feedback:
CVVHD facilitates the removal of uremic toxins and fluid. The hemodynamic
effects of CVVHD are usually mild in comparison to hemodialysis, so CVVHD is
best tolerated by an unstable patient. Peritoneal dialysis is not the best choice,as the
patient may have sustained abdominal injuries during the accident and catheter
placement would be risky. Plasmapheresis does not achieve fluid removal and
electrolyte balance.
21. A patient has presented with signs and symptoms that are characteristic of acute
kidney injury, but preliminary assessment reveals no obvious risk factors for this
health problem. The nurse should recognize the need to interviewthe patient about
what topic?
A) Typical diet
B) Allergy status
C) Psychosocial stressors
D) Current medication use
Ans: D
Feedback:
The kidneys are susceptible to the adverse effects of medications because they are
repeatedly exposed to substances in the blood. Nephrotoxic medications are a more
likely cause of AKI than diet,allergies, or stress.
22. An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for
surgical treatment. The patient has been on chemotherapeutic agents to decrease the
tumor size prior to the planned surgery. The nurse caring for the patient is aware that
what precipitating factors in this patient may contribute to AKI? Select all that apply.
A) Anxiety
B) LowBMI
C) Age-related physiologic changes
D) Chronic systemic disease
E) NPO status
Ans: C, D
Feedback:
Changes in kidney function with normal aging increase the susceptibility of elderly
patients to kidney dysfunction and renal failure. In addition, the presence of chronic,
systemic diseases increases the risk of AKI. LowBMIand anxiety are not risk
factors for acute renal disease. NPO status is not arisk, provided adequate parenteral
hydration is administered.
23. A patient is being treated for AKIand the patient daily weights have been ordered.
The nurse notes a weight gain of 3 pounds over the past 48 hours. What nursing
diagnosis is suggested by this assessment finding?
A) Imbalanced nutrition: More than body requirements
B) Excess fluid volume
C) Sedentary lifestyle
D) Adult failure to thrive
Ans: B
Feedback:
If the patient with AKI gains or does not lose weight, fluid retention should be
suspected. Short-term weight gain is not associated with excessive caloric intake or
asedentary lifestyle. Failure to thrive is not associated with weight gain.
24. A15-year-old is admitted to the renal unit with a diagnosis of postinfectious
glomerular disease. The nurse should recognize that this form of kidney disease may
have been precipitated by what event?
A) Psychosocial stress
B) Hypersensitivity to an immunization
C) Menarche
D) Streptococcal infection
Ans: D
Feedback:
Postinfectious causes of postinfectious glomerular disease are group Abetahemolytic streptococcal infection of the throat that precedes the onset of
glomerulonephritis by 2 to 3 weeks. Menarche, stress,and hypersensitivity are not
typical causes.
25. A patient on the medical unit has a documented history of polycystic kidney disease
(PKD). What principle should guide the nurses care of this patient?
A) The disease is self-limiting and cysts usually resolve spontaneously in the fifth
or sixth decade of life.
B) The patients disease is incurable and the nurses interventions will be
supportive.
C) The patient will eventually require surgical removal of his or her renal cysts.
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D) The patient is likely to respond favorably to lithotripsy treatment of the cysts.
Ans: B
Feedback:
PKD is incurable and care focuses on support and symptom control. It is not selflimiting and is not treated surgically or with lithotripsy.
26. The nurse is providing a health education workshop to a group of adults focusing on
cancer prevention. The nurse should emphasize what action in order to reduce
participants risks of renal carcinoma?
A) Avoiding heavy alcohol use
B) Control of sodium intake
C) Smoking cessation
D) Adherence to recommended immunization schedules
Ans: C
Feedback:
Tobacco use is asignificant risk factor for renal cancer, surpassing the significance
of high alcohol and sodium intake. Immunizations do not address an individuals risk
of renal cancer.
27. The nurse performing the health interviewof a patient with a newonset of
periorbital edema has completed a genogram, noting the health history of the
patients siblings, parents,and grandparents. This assessment addresses the patients
risk of what kidney disorder?
A) Nephritic syndrome
B) Acute glomerulonephritis
C) Nephrotic syndrome
D) Polycystic kidney disease (PKD)
Ans: D
Feedback:
PKD is a genetic disorder characterized by the growth of numerous cysts in the
kidneys. Nephritic syndrome,acute glomerulonephritis,and nephrotic syndrome are
not genetic disorders.
28. A patient is brought to the renal unit from the PACU status post resection of arenal
tumor. Which of the following nursing actions should the nurse prioritize in the care
of this patient?
A) Increasing oral intake
B) Managing postoperative pain
C) Managing dialysis
D) Increasing mobility
Ans: B
Feedback:
The patient requires frequent analgesia during the postoperative period and
assistance with turning,coughing, use of incentive spirometry,and deep breathing to
prevent atelectasis and other pulmonary complications. Increasing oral intake and
mobility are not priority nursing actions in the immediate postoperative care of this
patient. Dialysis is not necessary following kidney surgery.
29. Anurse is caring for a patient who is in the diuresis phase of AKI. The nurse should
closely monitor the patient for what complication during this phase?
A) Hypokalemia
B) Hypocalcemia
C) Dehydration
D) Acute flank pain
Ans: C
Feedback:
The diuresis period is marked by a gradual increase in urine output, which signals
that glomerular filtration has started to recover. The patient must be observed
closely for dehydration during this phase; if dehydration occurs, the uremic
symptoms are likely to increase. Excessive losses of potassium and calcium are not
typical during this phase,and diuresis does not normally result in pain.
30. The nurse is caring for a patient status after a motor vehicle accident. The patient has
developed AKI. What is the nurses role in caring for this patient? Select all that
apply.
A) Providing emotional support for the family
B) Monitoring for complications
C) Participating in emergency treatment of fluid and electrolyte imbalances
D) Providing nursing care for primary disorder (trauma)
E) Directing nutritional interventions
Ans: A, B, C, D
Feedback:
The nurse has an important role in caring for the patient with AKI. The nurse
monitors for complications, participates in emergency treatment of fluid and
electrolyte imbalances,assesses the patients progress and response to treatment,
and provides physical and emotional support. Additionally, the nurse keeps family
members informed about the patients condition, helps them understand the
treatments,and provides psychological support. Although the development of AKI
may be the most serious problem, the nurse continues to provide nursing care
indicated for the primary disorder (e.g., burns, shock, trauma, obstruction of the
urinary tract). The nurse does not direct the patients nutritional status; the dietician
and the physician normally collaborate on directing the patients nutritional status.
31. A71-year-old patient with ESKD has been told by the physician that it is time to
consider hemodialysis until atransplant can be found. The patient tells the nurse she
is not sure she wants to undergo a kidney transplant. What would be an appropriate
response for the nurse to make?
A) The decision is certainly yours to make, but be sure not to make a mistake.
B) Kidney transplants in patients your age are as successful as they are in younger
patients.
C) I understand your hesitancy to commit to atransplant surgery. Success is
comparatively rare.
D) Have you talked this over with your family?
Ans: B
Feedback:
Although there is no specific age limitation for renal transplantation,concomitant
disorders (e.g.,coronary artery disease, peripheral vascular disease) have made it a
less common treatment for the elderly. However, the outcome is comparable to that
of younger patients. The other listed options either belittle the patient or give the
patient misinformation.
32. The nurse has identified the nursing diagnosis of risk for infection in a patient who
undergoes peritoneal dialysis. What nursing action best addresses this risk?
A) Maintain aseptic technique when administering dialysate.
B) Wash the skin surrounding the catheter site with soap and water prior to each
exchange.
C) Add antibiotics to the dialysate as ordered.
D) Administer prophylactic antibiotics by mouth or IVas ordered.
Ans: A
Feedback:
Aseptic technique is used to prevent peritonitis and other infectious complications
of peritoneal dialysis. It is not necessary to cleanse the skin with soap and water
prior to each exchange. Antibiotics may be added to dialysate to treat infection, but
they are not used to prevent infection.
33. The nurse is caring for a patient who has returned to the postsurgical suite after
post-anesthetic recovery from a nephrectomy. The nurses most recent hourly
assessment reveals asignificant drop in level of consciousness and BP as well as
scant urine output over the past hour. What is the nurses best response?
A) Assess the patient for signs of bleeding and inform the physician.
B) Monitor the patients vital signs every 15 minutes for the next hour.
C) Reposition the patient and reassess vital signs.
D) Palpate the patients flanks for pain and inform the physician.
Ans: A
Feedback:
Bleeding may be suspected when the patient experiences fatigue and when urine
output is less than 30 mL/h. The physician must be made aware of this finding
promptly. Palpating the patients flanks would cause intense pain that is of no benefit
to assessment.
34. The critical care nurse is monitoring the patients urine output and drains following
renal surgery. What should the nurse promptly report to the physician?
A) Increased pain on movement
B) Absence of drain output
C) Increased urine output
D) Blood-tinged serosanguineous drain output
Ans: B
Feedback:
Urine output and drainage from tubes inserted during surgery are monitored for
amount,color,and type or characteristics. Decreased or absent drainage is promptly
reported to the physician because it may indicate obstruction that could cause pain,
infection,and disruption of the suture lines. Reporting increased pain on movement
has nothing to do with the scenario described. Increased urine output and
serosanguineous drainage are expected.
35. The nurse is creating an education plan for a patient who underwent a nephrectomy
for the treatment of arenal tumor. What should the nurse include in the teaching
plan?
A) The importance of increased fluid intake
B) Signs and symptoms of rejection
C) Inspection and care of the incision
D) Techniques for preventing metastasis
Ans: C
Feedback:
The nurse teaches the patient to inspect and care for the incision and perform other
general postoperative care, including activity and lifting restrictions, driving,and
pain management. There would be no need to teach the signs or symptoms of
rejection as there has been no transplant. Increased fluid intake is not normally
recommended and the patient has minimal control on the future risk for metastasis.
36. A patient with chronic kidney disease has been hospitalized and is receiving
hemodialysis on a scheduled basis. The nurse should include which of the following
actions in the plan of care?
A) Ensure that the patient moves the extremity with the vascular access site as
little as possible.
B) Change the dressing over the vascular access site at least every 12 hours.
C) Utilize the vascular access site for infusion of IVfluids.
D) Assess for athrill or bruit over the vascular access site each shift.
Ans: D
Feedback:
The bruit, or thrill, over the venous access site must be evaluated at least every
shift. Frequent dressing changes are unnecessary and the patient does not normally
need to immobilize the site. The site must not be used for purposes other than
dialysis.
37. The nurse is caring for a patient who has just returned to the post-surgical unit
following renal surgery. When assessing the patients output from surgical drains,
the nurse should assess what parameters? Select all that apply.
A) Quantity of output
B) Color of the output
C) Visible characteristics of the output
D) Odor of the output
E) pH of the output
Ans: A, B, C
Feedback:
Urine output and drainage from tubes inserted during surgery are monitored for
amount,color,and type or characteristics. Odor and pH are not normally assessed.
38. The nurse is caring for a patient after kidney surgery. The nurse is aware that
bleeding is a major complication of kidney surgery and that if it goes undetected and
untreated can result in hypovolemiaand hemorrhagic shock in the patient. When
assessing for bleeding, what assessment parameter should the nurse evaluate?
A) Oral intake
B) Pain intensity
C) Level of consciousness
D) Radiation of pain
Ans: C
Feedback:
Bleeding is a major complication of kidney surgery. If undetected and untreated, this
can result in hypovolemiaand hemorrhagic shock. The nurses role is to observe for
these complications, to report their signs and symptoms,and to administer
prescribed parenteral fluids and blood and blood components. Monitoring of vital
signs, skin condition, the urinary drainage system, the surgical incision,and the level
of consciousness is necessary to detect evidence of bleeding, decreased circulating
blood,and fluid volume and cardiac output. Bleeding is not normally evidenced by
changes in pain or oral intake.
39. Anurse on the renal unit is caring for a patient who will soon begin peritoneal
dialysis. The family of the patient asks for education about the peritoneal dialysis
catheter that has been placed in the patients peritoneum. The nurse explains the three
sections of the catheter and talks about the two cuffs on the dialysis catheter. What
would the nurse explain about the cuffs? Select all that apply.
A) The cuffs are made of Dacron polyester.
B) The cuffs stabilize the catheter.
C) The cuffs prevent the dialysate from leaking.
D) The cuffs provide a barrier against microorganisms.
E) The cuffs absorb dialysate
Ans: A, B, C, D
Feedback:
Most of these catheters have two cuffs, which are made of Dacron polyester. The
cuffs stabilize the catheter, limit movement, prevent leaks,and provide a barrier
against microorganisms. They do not absorb dialysate.
40. A patient with chronic kidney disease is completing an exchange during peritoneal
dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the
patients abdomen is increasing in girth. What is the nurses most appropriate action?
A) Advance the catheter 2 to 4 cm further into the peritoneal cavity.
B) Reposition the patient to facilitate drainage.
C) Aspirate from the catheter using a 60-mL syringe.
D) Infuse 50 mL of additional dialysate.
Ans: B
Feedback:
If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by
turning the patient from side to side or raising the head of the bed. The catheter
should never be pushed further into the peritoneal cavity. It would be unsafe to
aspirate or to infuse more dialysate.
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