265 exam 1

The nurse is caring for a client who is experiencing acute kidney injury (AKI) with polyuria. Which of the following actions is appropriate for the nurse to take?

• Administer furosemide as prescribed

• Obtain a prescription to discontinue IV fluids

• Monitor the client's indwelling urethral catheter output hourly

• Decrease the clients dietary potassium intake

The nurse is reviewing the laboratory results of assigned clients. It is a priority for the nurse to follow up with the primary health care provider (PHCP) if a client who...

• is receiving enoxaparin post-op from cardiac surgery and has a platelet count that has decreased from 200,000 to 175,000 mm^3 & nbsp over the past 2 days

• is receiving digoxin and has a blood urea nitrogen (BUN) level that has increased from 15 to 19 mg/dL over the past 3 days.

• has kidney stones, a serum creatinine level of 2.2 mg/dL, a serum sodium level of 133 mEq/L, and oliguria.

• has end-stage renal disease (ESRD), a serum potassium level of 5.5 mEq/L, and is scheduled for hemodialysis in 1 hour.

The nurse is caring for a client who has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which of the following should the nurse report immediately to the primary health care provider (PHCP)?

• A Glasgow Coma Scale (GCS) score that has decreased from 15 to 11.

• A decreased glomerular filtration rate (GFR).

• A blood urea nitrogen (BUN) level of 67 mg/dL.

• A creatinine level of 3 mg/dL.

The nurse is caring for a client who is receiving IV gentamicin for an infection and has developed oliguria and an increased blood pressure. Which of the following is a priority nursing action?

• Collect a urine sample to check the specific gravity.

• Insert an indwelling urethral catheter.

• Raise the head of the bed (HOB) to a 45-degree angle.

• Collect a specimen for a gentamicin peak and trough levels.

The nurse is caring for a client who has chronic kidney disease (CKD). The client has developed an increase in the rate and depth of respirations. After raising the client's head of bed (HOB), which of the following actions should the nurse take next?

• Evaluate the client's urine output for the past 4 hours.

• Obtain a blood specimen for arterial blood gases (ABG).

• Review the most recent serum potassium level.

• Determine if the client is scheduled to receive hemodialysis.

The nurse is talking with a client who has chronic kidney disease (CKD) and is receiving hemodialysis 3 times per week. Which of the following client statements is a priority for follow-up by the nurse?

• "I have noticed that my skin looks like it has a layer of frost on it."

• "I have noticed that my breath has developed a very unpleasant odor."

• "I will make sure to include eggs. apples, and green beans in my diet."

• "I try and limit my intake of dietary sodium to 5 grams per day."

The nurse is teaching a client who is in the late stage of chronic kidney disease (CKD). Which of the following client statements indicates a correct understanding of the teaching?

• "If I develop any muscle weakness or tremors, I should report it to my doctor."

• "Hemodialysis will be performed 2 times per week in an outpatient center."

• "I should avoid obtaining much of my protein from meat and eggs."

• "I can expect to have an increase in my energy level after a dialysis treatment."

The nurse is caring for a client who has just returned from receiving a hemodialysis treatment. It requires immediate follow-up by the nurse if the client has

• developed a temperature of 99.4

• a potassium level that decreased from 6.1 to 5.1 mEq/L.

• developed a pulse of 130.

• a report of feeling tired.

The nurse is caring for assigned clients. Which of the following actions should the nurse take?

• Place a mask on a client when changing the client's peritoneal dialysis (PD) catheter dressing.

• Obtain a blood specimen from a client's arteriovenous (AV) fistula.

• Apply a pressure dressing on a client's AV fistula between hemodialysis treatments.

• Walk a client to the bathroom during the peritoneal dialysis (PD) infusion cycle.

The nurse preceptor is observing a newly hired nurse care for a client who is receiving their morning peritoneal dialysis (PD). It requires follow-up by the nurse preceptor if the newly hired nurse is observed....

• monitoring and recording the client's vital signs (VS) every 30 minutes.

• obtaining a prescription to give the client an enema prior to beginning dialysis.

• warming a the dialysate bag in the warming chamber of the automated cycling chamber.

• instructing the patient to maintain a prone position while the dialysate bag is dwelling.