ASSESSMENT
The nurse tells the client with diabetes mellitus that it is important to maintain the dwell time for the peritoneal dialysis at the prescribed time because of the risk of:
Hyperglycemia
The client with acute renal failure has a serum potassium level of 5.8 mEq/L. The nurse would plan --------- as a priority action.
Place the client on a cardiac monitor
The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication___
On return from dialysis
The client with chronic renal failure has an indwelling catheter for peritoneal dialysis in the abdomen. The client spills water on the catheter dressing while bathing. The nurse should immediately___
Change the dressing
The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the client best understands the information given if the client states to record the daily _____
Intake, output, and weight
The nurse is caring for a hospitalized client who has chronic renal failure. Which nursing diagnoses is most appropriate for this client?
Excess Fluid Volume
The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. The nurse should ___
Check the peritoneal dialysis system for kinks
The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The nurse should_____
Discontinue dialysis and notify the physician
In planning teaching strategies for the client with chronic renal failure, the nurse must keep in mind the neurologic impact of uremia. Which teaching strategy would be most appropriate?
Validating frequently the client’s understanding of the material.
Your patient with cirrhosis has severe splenomegaly. As the nurse, you will make it a priority to monitor the patient for signs and symptoms of ____
Thrombocytopenia
Increased PT
Increased INRLeukopenia
Which nursing interventions should be included in the client’s care plan during dialysis therapy?
Monitor the client’s blood pressure
When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome?
use smallest gauge needle possible when giving injections or drawing blood.
teach ptn to avoid straining at stool, vigorous blowing of the nose, and coughing
advises pt to use soft-bristle toothbrush and avoid ingestion of irritating food.
instruct pt to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.
A patient with late-stage cirrhosis develops portal hypertension. Which complication can develop from this condition?
Esophageal varices
Ascites
Splenomegaly
The nurse is reviewing the lab results for a patient with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this patient?
Low-protein
Low fat
Low carbs
During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition, while assessing the upper extremities, the patient’s hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings?
Increased ammonia level
Which is the most significant sign of peritoneal infection?
Cloudy dialysate fluid
Which client is at greatest risk for developing acute renal failure?
A client with diabetes who has a heart catheterization
A client is diagnosed with chronic renal failure and told she must start hemodialysis. Client teaching would include ____ instructions
Strictly follow the hemodialysis schedule
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of a headache and nausea and is extremely restless. Which is the most appropriate nursing action?
Notify the physician
The physician orders Lactulose 30 mL by mouth per day for a patient with cirrhosis. What findings below demonstrates the medication is working effectively?
The decrease in Fetor Hepaticus
The patient is stuporous.
Decreased ammonia blood level
You are receiving a shift report on a patient with cirrhosis. The nurse tells you the patient’s bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment?
Dark brown urine
Yellowing of the sclera
Jaundice of the skin
The nurse is reviewing a list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response knowing that the glucose_____
Increases osmotic pressure to produce ultrafiltration
The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for_____
Headache,
deteriorating level of consciousness,
twitching
The nurse is preparing to care for a client receiving peritoneal dialysis. What would be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis?
Maintain strict aseptic technique
he hemodialysis client with a left arm fistula is at risk for steal syndrome. The nurse assesses this client for _____ clinical manifestations.
Pallor,
diminished pulse,
pain in the left hand.