Renal/GI/Cardiac

Front

The nurse has taught the client with suspected gallbladder disease about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? Options: “I know I must sign the consent form.”, I hope the throat spray keeps me from gagging, I’m glad I don’t have to lie still for this procedure., I’m glad some intravenous medication will be given to relax me.

Back

I’m glad I don’t have to lie still for this procedure.

Answer explanation

Rationale: The client does have to lie still for ERCP, which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.

Front

How would the nurse assess for the presence of asterixis in a client with cirrhosis? Options: Dorsiflex the client’s foot, Measure the abdominal girth, Ask the client to extend the arms, Instruct the client to lean forward.

Back

Ask the client to extend the arms.

Answer explanation

Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.

Front

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client?

Back

Pasta with sauce

Answer explanation

Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. Foods high in protein would be avoided since the client’s ammonia level is elevated above the normal range; therefore, pasta with sauce would be the best selection.

Front

The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? Options: Presence of a radial pulse in the left wrist, Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand, Palpation of a thrill over the fistula, Visualization of enlarged blood vessels at the fistula site

Back

Palpation of a thrill over the fistula

Answer explanation

Rationale: The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicates patency of the fistula. Enlarged visible blood vessels at the fistula site are a normal observation but are not indicative of fistula patency. Although the presence of a radial pulse in the left wrist and capillary refill of less than 3 seconds in the nail beds of the fingers on the left hand indicate adequate circulation to the hand, they do not assess fistula patency.

Front

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 101.2° F (38.5° C ). Which nursing action is most appropriate?

Back

Notify the primary health care provider.

Answer explanation

A temperature of 101.2° F (38.5° C) is significantly elevated and may indicate infection. The nurse would notify the primary health care provider (PHCP). Dialysis clients cannot have fluid intake encouraged. Vital signs and the shunt site should be monitored, but the PHCP needs to be notified first

Front

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

Back

Elevated creatinine level

Answer explanation

Rationale: The creatinine level is the most specific laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with decreased renal function. Increased white blood cells in the urine are noted with urinary tract infection.

Front

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. The client’s urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client’s blood urea nitrogen level is 35 mg/dL (12.6 mmol/L), and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority?

Back

Call the primary health care provider

Answer explanation

Rationale: Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. Normal reference levels are BUN 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine 0.5 to 1.2 mg/dL (44 to 106 mcmol/L). Continuing to monitor urine output or checking other parameters can wait. Urine output lower than 30 mL/hr is reported to the PHCP for urgent treatment.

Front

A client with a history of type 2 diabetes is admitted to the hospital with chest pain and scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?

Back

Metformin

Answer explanation

Rationale: Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld before and after cardiac catheterization.

Front

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client’s breath sounds?

Back

Crackles

Answer explanation

Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway

Front

A client with myocardial infarction is developing cardiogenic shock. Which potential condition would the nurse anticipate and monitor the client for to detect cardiogenic shock?

Back

Ventricular dysrhythmias

Answer explanation

Rationale: Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure become apparent. Pulsus paradoxus is a finding associated with cardiac tamponade.