CHAMBERLAIN COLLEGE OF NURSING: COMPLEX CRITICAL NURSING 341 TEST 1 Ch 13 . 100% Correct

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1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30... breaths/min, and temperature of 100.5°. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient’s plan of care? a. Frequent neurological assessments b. Side to side position changes c. Range of motion to extremities d. Frequent oropharyngeal suctioning Nurses complete neurological assessments based on ordered frequency and the severity of the patient’s condition. The newly admitted patient has an altered neurological status so frequent neurological assessments are most important to include in the patient’s plan of care. Side to side position changes, range of motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patient’s plan of care but in the setting of increased intracranial pressure should not be regularly performed unless indicated. DIF: Cognitive Level: Application REF: p. 365 | Nursing Care Plan OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? a. 54 mm Hg b. 72 mm Hg c. 90 mm Hg d. 126 mm Hg CPP = MAP – ICP. In this case, CPP = 108 mm Hg – 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect. DIF: Cognitive Level: Comprehension REF: pp. 360-361 OBJ: Complete an assessment on a critically ill patient with nervous system injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? a. Both pressures are high. b. Both pressures are low. c. ICP is high; CPP is normal. d. ICP is high; CPP is low. The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range. All other listed responses are incorrect. DIF: Cognitive Level: Comprehension REF: p. 361 OBJ: Complete an assessment on a critically ill patient with nervous system injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patient’s head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d. Provide rest periods between nursing interventions. Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patient’s plan of care; however, spacing out interventions is the priority. DIF: Cognitive Level: Application REF: p. 365 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 5. While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient’s left naris. What is the best nursing action? a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears. In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear. DIF: Cognitive Level: Application REF: p. 374 OBJ: Describe the nursing and medical management of patients with skull fractures. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 6. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a. Stimulate the patient hourly. b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the physician immediately. These are classic symptoms of epidural and acute subdural hematomas: injury, lucid period, and progressive deterioration. The physician must be notified of this neurological emergency so appropriate interventions can be implemented. Although elevating the head of the bed, continuously monitoring the patient and applying stimulation as necessary to assess neurological response are appropriate interventions, notification of the physician is a priority given the severity in change of neurological status. DIF: Cognitive Level: Analysis REF: p. 376 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary. DIF: Cognitive Level: Application REF: p. 370 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal) Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume. Cerebral vessels dilate when CO2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume. DIF: Cognitive Level: Knowledge REF: p. 366 OBJ: Describe the pathophysiology of increased intracranial pressure. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a. Monitor the patient’s airway patency. b. Elevate the head of the patient’s bed. c. Increase supplemental oxygen delivery. d. Support bony prominences with padding. A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patient’s airway. There is no evidence to support the need for increased supplemental oxygen. A respiratory rate of 10 breaths/min may result in increased CO2 retention, which may further increase ICP through dilatation of cerebral vessels. Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however, airway patency is the immediate priority. DIF: Cognitive Level: Application REF: pp. 355-356 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation. This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation. DIF: Cognitive Level: Comprehension REF: p. 366 OBJ: Complete an assessment on a critically ill patient with nervous system injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad. Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care. DIF: Cognitive Level: Application REF: p. 374 OBJ: Describe the nursing and medical management of patients with skull fractures. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102° F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a. Ensure adequate periods of rest between nursing interventions. b. Insert an oral airway and monitor respiratory rate and depth. c. Maintain neutral head alignment and avoid extreme hip flexion. d. Reduce ambient room temperature and administer antipyretics. In this scenario, the patient’s temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority. DIF: Cognitive Level: Application REF: p. 369 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 13. The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patient’s mouth and insert a padded tongue blade. d. Restrain the patient’s extremities until the seizure subsides. To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported. Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration. Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient’s jaws will be clenched shut. Forceful insertion may lead to further injury. Restraining a patient during seizure activity can be traumatizing and is not standard of care. DIF: Cognitive Level: Application REF: p. 387 OBJ: Describe the pathophysiology and management for status epilepticus. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 14. The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35-45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg. DIF: Cognitive Level: Comprehension REF: Nursing Care Plan: Spinal Cord Injury OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 15. The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the physician of the patient’s blood pressure. Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distention. Other causes that should be ruled out prior to pharmacological intervention include fecal impaction. Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause. Slow deep breathes will not correct the underlying problem. Assessing for underlying causes of autonomic dysreflexia should precede contacting the physician. DIF: Cognitive Level: Application REF: Box 13-5 OBJ: Describe nursing and medical management of patients with a spinal cord injury. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 16. The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a. Assess for the presence of a headache. b. Assess the patient’s general orientation. c. Determine the patient’s drug allergies. d. Determine the time of symptom onset. Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment. DIF: Cognitive Level: Application REF: p. 379 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg. DIF: Cognitive Level: Analysis REF: pp. 393-394 OBJ: Describe nursing and medical management of patients with a spinal cord injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED. Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury. Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patient’s airway is compromised. The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out. DIF: Cognitive Level: Comprehension REF: p. 392 OBJ: Describe nursing and medical management of patients with a spinal cord injury. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 19. The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper hand washing. Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority. DIF: Cognitive Level: Comprehension REF: pp. 393-394 OBJ: Describe nursing and medical management of patients with a spinal cord injury. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 20. The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient? a. 2478 mg b. 5000 mg c. 10,794 mg d. 12,750 mg The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg  70 kg) + (5.4 mg  70 kg)  23 hours = 10,794 mg. DIF: Cognitive Level: Comprehension REF: Table 13-9 OBJ: Describe nursing and medical management of patients with a spinal cord injury. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 21. The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which physician order should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous The patient’s GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario. DIF: Cognitive Level: Analysis REF: Table 13-9 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which physician order should the nurse institute first? a. Blood cultures (2 specimens) for temperature > 101° F b. Acetaminophen (Tylenol) 650 mg per rectum c. 500 mL albumin infusion intravenously d. Decadron 20 mg intravenous push every 4 hours Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario. DIF: Cognitive Level: Analysis REF: p. 384 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine (Cardene) infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient’s blood pressure to be 160/90 mm Hg. What is the best action by the nurse? a. Stop the infusion for 5 minutes. b. Increase the dose by 2.5 mg/hr. c. Notify the physician of the BP. d. Begin weaning the infusion. Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patient’s blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse. Stopping the infusion or weaning the infusion is contraindicated before reaching the desired blood pressure. Notifying the physician of the blood pressure is not indicated until the upper limits of the infusion are reached without achieving the desired blood pressure. DIF: Cognitive Level: Analysis REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 24. The nurse is preparing to administer a routine dose of phenytoin (Dilantin). The physician orders phenytoin (Dilantin) 500 mg intravenous every 6 hours. What is the best action by the nurse? a. Administer over 2 minutes. b. Administer with 0.9% normal saline intravenous. c. Contact the physician. d. Assess cardiac rhythm. The ordered dose is an inappropriate maintenance dose. The nurse should contact the physician. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters. DIF: Cognitive Level: Application REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 25. The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order by the physician should the nurse implement first? a. Obtain stat serum electrolytes. b. Administer lorazepam (Ativan). c. Obtain stat portable chest x-ray. d. Administer phenytoin (Dilantin). The nurse should administer lorazepam (Ativan) as ordered; lorazepam (Ativan) is the first-line medication for the treatment of status epilepticus. Phenytoin (Dilantin) is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario. DIF: Cognitive Level: Application REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 26. The physician orders fosphenytoin (Cerebyx), 1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus. What is the most important action by the nurse? a. Contact the admitting physician. b. Administer drug over 10 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line. The nurse can administer the medication over 10 minutes as ordered (100-150 mg phenytoin equivalent [PE] over 1 full minute). The drug dose ordered is appropriate for the patient’s weight. Fosphenytoin (Cerebyx) does not have to be administered with normal saline or via a central line. DIF: Cognitive Level: Application REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 27. The nurse is to administer 100 mg phenytoin (Dilantin) intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? a. Administer over 2 minutes. b. Administer over 5 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line. In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario. Administering the medications via central line will not prevent complications related to this scenario. DIF: Cognitive Level: Application REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 28. The nurse is preparing to administer 100 mg of phenytoin (Dilantin) to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse? a. Ensure patency of intravenous (IV) line. b. Mix drug with 0.9% normal saline. c. Evaluate serum K+ level. d. Obtain an IV infusion pump. Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis). Mixing the drug with normal saline prevents crystallization of the medication and would be noticed prior to administration. Evaluating the serum K+ is not required prior to administration. The dose of phenytoin (Dilantin) ordered can be safely administered IV push over 2 minutes and does not require an infusion pump. DIF: Cognitive Level: Comprehension REF: Table 13-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 29. The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the physician orders, which order is of the highest priority? a. Lasix 20 mg intravenous push as needed b. 500 mL albumin intravenous infusion c. Decadron 10 mg intravenous push d. Dilantin 50 mg intravenous push To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications. DIF: Cognitive Level: Application REF: p. 384 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 30. After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104° F as this is an abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis and droplet precautions are appropriate for a patient with bacterial meningitis. DIF: Cognitive Level: Analysis REF: Nursing Care Plan: Traumatic Brain Injury OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 31. The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a. Implement droplet precautions upon admission. b. Wash hands thoroughly before leaving the room. c. Scrub the hub of all central line ports prior to use. d. Dispose of all bloody dressings in biohazard bags. Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection. Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis. DIF: Cognitive Level: Comprehension REF: p. 388 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control 32. The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is the priority nursing action? a. Elevate the head of the bed 30 degrees. b. Keep lights dim at all times. c. Implement seizure precautions. d. Maintain bedrest at all times. Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation such photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury. Elevating the head of the bead, keeping the lights dim, and maintaining bedrest are all appropriate nursing interventions but are not the priorities in this scenario. DIF: Cognitive Level: Application REF: p. 388 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b. Manually flushing the device “prn” c. Recording ICP as a “mean” value d. Use of a pressurized flush system e. Zero referencing the transducer system , E Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Munro. Manually flushing the device may result in an increase in ICP. DIF: Cognitive Level: Knowledge REF: p. 362 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Doll’s eyes absent indicate a disruption in normal brainstem processing. b. Doll’s eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex. , B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll’s eye): turn the patient’s head quickly from side to side while holding the eyes open. Note movement of eyes. The doll’s eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement. DIF: Cognitive Level: Comprehension REF: pp. 393-396 OBJ: Complete an assessment on a critically ill patient with nervous system injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient’s plan of care? (Select all that apply.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e. Restrain affected limb to prevent injury. , C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided. Ch 15 1. With sudden cessation of renal function, all body systems are affected by the inability to maintain fluid and electrolyte balance and eliminate metabolic waste. In critically ill patients, renal dysfunction: a. is a very rare problem. b. affects nearly two thirds of patients. c. has a low mortality once renal replacement therapy has been initiated. d. has little effect on morbidity, mortality, or quality of life. The kidney is the primary regulator of the body’s internal environment. With sudden cessation of renal function, all body systems are affected by the inability to maintain fluid and electrolyte balance and eliminate metabolic waste. Renal dysfunction is a common problem in critically ill patients with nearly two thirds of patients experiencing some degree of renal dysfunction. The most severe cases requiring renal replacement therapy have a reported mortality of 50% to 60%. Acute kidney injury that progresses to chronic renal failure is associated with increased morbidity, mortality and reduced quality of life. DIF: Cognitive Level: Comprehension REF: p. 432 OBJ: Review the anatomy and physiology of the renal system. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient’s urinalysis results. The nurse should become concerned when a. creatinine levels in the urine are similar to blood levels of creatinine. b. sodium and chloride are found in the urine. c. urine uric acid levels have the same values as serum levels. d. red blood cells and albumin are found in the urine. Normal glomerular filtrate is basically protein free and contains electrolytes, including sodium, chloride, and phosphate, and nitrogenous waste products, such as creatinine, urea, and uric acid, in amounts similar to those in plasma. Red blood cells, albumin, and globulin are too large to pass through the healthy glomerular membrane. Their presence in urine may indicate glomerular damage. DIF: Cognitive Level: Comprehension REF: p. 433 OBJ: Review the anatomy and physiology of the renal system. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A normal glomerular filtration rate is: a. less than 80 mL/min. b. 80 to 125 mL/min c. 125 to 180 mL/min d. more than 189 mL/min At a normal glomerular filtration rate (GFR) of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate. As the filtrate passes through the various components of the nephron’s tubules, 99% is reabsorbed into the peritubular capillaries or vasa recta. DIF: Cognitive Level: Knowledge REF: p. 434 OBJ: Review the anatomy and physiology of the renal system. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. A normal urine output is considered to be: a. 80 to 125 mL/min. b. 180 L/day. c. 80 mL/min. d. 1 to 2 L/day. At a normal glomerular filtration rate (GFR) of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate. As the filtrate passes through the various components of the nephron’s tubules, 99% is reabsorbed into the peritubular capillaries or vasa recta. Eventually, the remaining filtrate (1% of the original 180 L/day) is excreted as urine, for an average urine output of 1 to 2 L/day. DIF: Cognitive Level: Knowledge REF: p. 434 OBJ: Review the anatomy and physiology of the renal system. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. Renin plays a role in blood pressure regulation by: a. activating the renin-angiotensin-aldosterone cascade. b. suppressing angiotensin production. c. decreasing sodium reabsorption. d. inhibiting aldosterone release. Specialized cells in the afferent and efferent arterioles and the distal tubule are collectively known as the juxtaglomerular apparatus. These cells are responsible for the production of a hormone called renin, which plays a role in blood pressure regulation. Renin is released whenever blood flow through the afferent and efferent arterioles decreases. A decrease in the sodium ion concentration of the blood flowing past the specialized cells (e.g., in hypovolemia) also stimulates the release of renin. Renin activates the renin-angiotensin-aldosterone cascade, which ultimately results in angiotensin II production. Angiotensin II causes vasoconstriction and release of aldosterone from the adrenal glands, thereby raising blood pressure and flow and increasing sodium and water reabsorption in the distal tubule and collecting ducts. DIF: Cognitive Level: Knowledge REF: p. 434 OBJ: Review the anatomy and physiology of the renal system. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse is caring for an elderly patient who was admitted with renal insufficiency. The nurse realizes that with advance age often comes declining renal function. An expected laboratory finding for this patient may be: a. an increased glomerular filtration rate (GFR). b. a normal serum creatinine level. c. increased ability to excrete drugs. d. hypokalemia. The most important renal physiological change that occurs with aging is a decrease in the GFR. After age 40, renal blood flow gradually diminishes at a rate of 10% per decade. With advancing age, there is also a decrease in renal mass, the number of glomeruli and peritubular density. Serum creatinine levels may remain the same in the elderly patient, even with a declining GFR, because of decreased muscle mass and hence decreased creatinine production. Tubular changes include a diminished ability to excrete drugs, including radiocontrast dyes used in diagnostic testing, which necessitates a decrease in drug dosing to avoid nephrotoxicity. Many medications, including antibiotics, require dose adjustments as kidney function declines. Age-related changes in renin and aldosterone levels also occur, which can lead to fluid and electrolyte abnormalities. Renin levels are decreased by 30% to 50% in the elderly, resulting in less angiotensin II production and lower aldosterone levels. Together these can cause an increased risk of hyperkalemia. The aging kidney is also slower to correct an increase in acids, causing a prolonged metabolic acidosis and the subsequent shifting of potassium out of cells and worsening hyperkalemia. DIF: Cognitive Level: Comprehension REF: p. 435 OBJ: Review the anatomy and physiology of the renal system. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The term used to describe an increase in blood urea nitrogen (BUN) and serum creatinine is: a. oliguria. b. azotemia. c. acute kidney injury. d. prerenal disease. Azotemia refers to increases in blood urea nitrogen and serum creatinine. Oliguria is defined as urine output less than 0.5 mL/kg/hr. Elevation of BUN and creatinine can be the result of acute kidney injury or chronic kidney diseases. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal. DIF: Cognitive Level: Knowledge REF: p. 435 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The most common cause of acute kidney injury in critically ill patients is: a. sepsis. b. fluid overload. c. medications. d. hemodynamic instability. The etiology of AKI in critically ill patients is often multifactorial and develops from a combination of hypovolemia, sepsis, medications, and hemodynamic instability. Sepsis is the most common cause of AKI. DIF: Cognitive Level: Knowledge REF: p. 436 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours. It is 0200 in the morning. The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats per minute. Previously, the pulse was 90 beats per minute with a blood pressure of 120/80 mm Hg. The nurse should: a. contact the provider and expect an order for a normal saline bolus. b. wait until 0900 when the provider makes rounds to report the assessment findings. c. continue to evaluate urine output for 2 more hours. d. ignore the urine output, as this is most likely postrenal in origin. Most prerenal causes of AKI are related to intravascular volume depletion, decreased cardiac output, renal vasoconstriction, or pharmacological agents that impair autoregulation and GFR (Box 15-2).8 These conditions reduce the glomerular perfusion and the GFR, and the kidneys are hypoperfused. For example, major abdominal surgery can cause hypoperfusion of the kidney as a result of blood loss during surgery or as a result of excess vomiting or nasogastric suction during the postoperative period. The body attempts to normalize renal perfusion by reabsorbing sodium and water. If adequate blood flow is restored to the kidney, normal renal function resumes. Most forms of prerenal AKI can be reversed by treating the cause. DIF: Cognitive Level: Analysis REF: p. 436 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. Acute kidney injury from post renal etiology is caused by: a. obstruction of the flow of urine. b. conditions that interfere with renal perfusion. c. hypovolemia or decreased cardiac output. d. conditions that act directly on functioning kidney tissue. Acute kidney injury resulting from obstruction of the flow of urine is classified as postrenal or obstructive renal injury. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal and include hypovolemia and decreased cardiac output. Conditions that produce AKI by directly acting on functioning kidney tissue are classified as intrarenal. DIF: Cognitive Level: Knowledge REF: pp. 436-437 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. Conditions that produce acute kidney injury by directly acting on functioning kidney tissue are classified as intrarenal. The most common intrarenal condition is: a. prolonged ischemia. b. exposure to nephrotoxic substances. c. acute tubular necrosis (ATN). d. hypotension for several hours. The most common intrarenal condition is ATN. This condition may occur after prolonged ischemia (prerenal), exposure to nephrotoxic substances, or a combination of these. Some patients have ATN after only several minutes of hypotension or hypovolemia, whereas others can tolerate hours of renal ischemia without having any apparent tubular damage. DIF: Cognitive Level: Knowledge REF: p. 437 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should: a. not be concerned unless urine output decreases. b. evaluate the patient’s serum creatinine for up to 72 hours after the procedure. c. obtain an order for a renal ultrasound. d. evaluate the patient’s post void residual volume to detect intrarenal injury. Contrast- induced kidney injury is diagnosed by an increase in serum creatinine of 25%, or 0.5 mg/dL, within 48 to 72 hours following the administration of contrast. Urine output usually remains normal. The renal ultrasound and postvoid residual assessment are not warranted. DIF: Cognitive Level: Analysis REF: p. 438 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. The nurse is caring for a patient with acute kidney injury who is being treated with hemodialysis. The patient asks if he will need dialysis for the rest of his life. Which of the following would be the best response? a. “Unfortunately, kidney injury is not reversible; it is permanent.” b. “Kidney function usually returns within 2 weeks.” c. “You will know for sure if you start urinating a lot all at once.” d. “recovery is possible, but it may take several months.” Renal dysfunction is potentially reversible during the initiation phase. This phase spans several hours to 2 days, during which time the normal renal processes begin to deteriorate, but actual intrinsic renal damage has not yet occurred. During the maintenance phase, intrinsic renal damage is established, and the GFR stabilizes at approximately 5 to 10 mL/min. This phase usually lasts 8 to 14 days, but it may last up to 11 months. The longer a patient remains in this stage, the slower the recovery and the greater the chance of permanent renal damage will be. The recovery phase is the period during which the renal tissue recovers and repairs itself. A gradual increase in urine output and an improvement in laboratory values occur. Recovery may take as long as 4 to 6 months. DIF: Cognitive Level: Comprehension REF: pp. 439-440 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. Which of the following patients is at the greatest risk of developing acute kidney injury? A patient who: a. has been on aminoglycosides for the past 6 days. b. has a history of controlled hypertension with a blood pressure of 138/88 mm Hg. c. was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks. d. has a history of fluid overload as a result of heart failure. Acute kidney injury can be caused by aminoglycoside nephrotoxicity, especially prolonged use of the drug (more than 10 days). Symptoms of acute kidney injury are usually seen about 1 to 2 weeks after exposure. Because of this delay, the patient must be questioned about any recent medical therapy for which an aminoglycoside may have been prescribed. The blood pressure of 138/88 mm Hg controlled by medication would not cause acute kidney injury, nor would fluid overload from exacerbation of heart failure. DIF: Cognitive Level: Analysis REF: p. 440 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate: a. increased nitrogen intake. b. acute kidney injury, such as acute tubular necrosis (ATN). c. hypovolemia. d. fluid resuscitation. A normal BUN/creatinine ratio is present in ATN. In ATN, there is actual injury to the renal tubules and a rapid decline in the GFR; hence, BUN and creatinine levels both rise proportionally as a result of increased reabsorption and decreased clearance. Hypovolemia would result in prerenal condition, which usually increases the BUN/creatinine ratio. DIF: Cognitive Level: Comprehension REF: p. 442 OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of laboratory values and radiological diagnostic tests. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The patient’s serum creatinine level is 0.7 mg/dL. The expected BUN level should be: a. 1-2 mg/dL. b. 7-14 mg/dL. c. 10-20 mg/dL. d. 20-30 mg/dL. The normal BUN/creatinine ratio is 10:1 to 20:1. Therefore, the expected range for this creatinine level would be 7 to 14 mg/dL. DIF: Cognitive Level: Analysis REF: p. 442 OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of laboratory values and radiological diagnostic tests. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. In determining the glomerular filtration rate (GFR) or creatinine clearance, a 24-hour urine is obtained. If a reliable 24-hour urine collection is not possible, a. it is not possible to determine the GFR. b. the BUN may be used to determine renal function. c. an elevated BUN/creatinine ratio can be used. d. a standardized formula may be used to calculate GFR. Historically, timed 24-hour urine collections have been used to evaluate GFR or creatinine clearance. If a reliable 24-hour urine collection is not possible, the Cockcroft and Gault formula may be used to determine the creatinine clearance from a serum creatinine value. The BUN level is not a reliable indicator of kidney function because the rate of protein metabolism is not constant. An increased BUN/creatinine ratio is typically noted with prerenal conditions, but does not provide an estimate of GFR. DIF: Cognitive Level: Comprehension REF: p. 442 OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of laboratory values and radiological diagnostic tests. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. In calculating the glomerular filtration rate (GFR) results for women, the creatinine clearance is usually: a. the same as for men. b. greater than that for men. c. multiplied by 0.85. d. multiplied by 1.15. For women, the calculated result is multiplied by 0.85 to account for the smaller muscle mass as compared to men. DIF: Cognitive Level: Knowledge REF: p. 442 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient’s urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has: a. acute kidney injury from a prerenal condition. b. acute kidney injury from postrenal obstruction. c. intrarenal disease, probably acute tubular necrosis. d. a urinary tract infection. Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of acute kidney injury. Coarse, muddy brown granular casts are classic findings in ATN. Microscopic hematuria and a small amount of protein also may be seen. In prerenal conditions, the urine typically has no cells but may contain hyaline casts. Postrenal conditions may present with stones, crystals, sediment, bacteria, and clots from the obstruction. Bacteria would be present in a urinary tract infection. DIF: Cognitive Level: Analysis REF: p. 442 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient’s condition is: a. prerenal. b. postrenal. c. intrarenal. d. not renal related. Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of acute kidney injury. Postrenal conditions may present with stones, crystals, sediment, bacteria, and clots from the obstruction. Coarse, muddy brown granular casts are classic findings in ATN (intrarenal), along with microscopic hematuria and a small amount of protein. In prerenal conditions, the urine typically has no cells but may contain hyaline casts. The flank pain and urinalysis definitely indicate a renal condition. DIF: Cognitive Level: Analysis REF: pp. 436-437 OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of laboratory values and radiological diagnostic tests. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. The patient is a new postoperative patient. She weighs 75 kg. The nurse expects the minimal acceptable urine output to be: a. less than 30 mL/hour. b. 37 mL/hour. c. 80 mL/hour. d. 150 mL/hour. Normal urine output is 0.5 to 1 mL/kg of body weight each hour. DIF: Cognitive Level: Comprehension REF: p. 447 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. Daily weights are being recorded for the patient. His urine output has been less than his intravenous and oral intake. His weight yesterday was 97.5 kg. This morning it is 99 kg. The nurse understands that this corresponds to a(n): a. fluid retention of 1.5 liters. b. fluid loss of 1.5 liters. c. equal intake and output due to insensible losses. d. fluid loss of 0.5 liters. A 1-kg gain in body weight is equal to a 1000-mL fluid gain. This patient has gained 1.5 kg, or 1.5 liters of fluid. DIF: Cognitive Level: Analysis REF: p. 446 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. Because mannitol is an osmotic diuretic, the nurse should: a. assess the patient’s hearing. b. assess the patient’s lungs. c. decrease IV fluids once the diuretic has been administered. d. give extra doses prior to giving radiological contrast agents. Mannitol, an osmotic diuretic often used in acute kidney injury caused by rhabdomyolysis, increases plasma volume. Patients may be at risk for the development of pulmonary edema due to the rapid expansion of intravascular volume triggered by mannitol. Hearing is assessed with administration of loop diuretics, such as furosemide, which have been associated with deafness. Aggressive fluid administration is required in rhabdomyolysis. Diuretics may increase the risk of acute kidney injury from volume depletion when they are given before procedures requiring radiological contrast agents or if the patient is hypovolemic. Adequate hydration prior to administration of diuretics is essential. DIF: Cognitive Level: Application REF: p. 448 OBJ: Describe the medical management of the patient with acute kidney injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The patient gets hemodialysis 3 days a week. He is 74 inches tall and weighs 100 kg. In planning the care for this patient, the nurse recommends: a. 2500 to 3500 kcal diet per day. b. protein intake less than 50 grams per day. c. potassium intake of 10 mEq per day. d. fluid intake of less than 500 mL per day. Nutritional recommendations include the following: caloric intake of 25 to 35 kcal/kg of ideal body weight per day (2500-3500 kcal) and protein intake of no less than 0.8 g/kg body weight. Patients who are extremely catabolic should receive 1.5 to 2 g/kg of ideal body weight per day, 75% to 80% of which contains all the required essential amino acids; sodium intake of 0.5 to 1.0 g/day; potassium intake of 20 to 50 mEq/day; calcium intake of 800 to 1200 mg/day; fluid intake equal to the volume of the patient’s urine output plus an additional 600 to 1000 mL/day. DIF: Cognitive Level: Application REF: p. 449 OBJ: Develop a plan of care for the patient with acute kidney injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The patient’s potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction? a. Kayexalate b. Kayexalate with sorbitol c. Regular insulin d. Calcium gluconate Only dialysis and administration of cation exchange resins (sodium polystyrene sulfonate [Kayexalate]) actually reduce plasma potassium levels and total body potassium content in a patient with renal dysfunction. In the past, sorbitol has been combined with sodium polystyrene sulfonate powder (Kayexalate) for administration. The concomitant use of sorbitol with Kayexalate has been implicated in cases of colonic intestinal necrosis; therefore, this combination is not recommended. Other treatments, such as administration of regular insulin and calcium gluconate only “protect” the patient for a short time until dialysis or cation exchange resins can be instituted. DIF: Cognitive Level: Knowledge REF: p. 449 OBJ: Describe the medical management of the patient with acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week. The patient complains of general malaise and is tachypneic. An arterial blood gas is ordered and shows that the patient’s pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to: a. administer morphine to slow the respiratory rate. b. prepare for intubation and mechanical ventilation. c. administer intravenous sodium bicarbonate. d. cancel tomorrow’s dialysis session. Metabolic acidosis is the primary acid-base imbalance seen in acute kidney injury. Treatment of metabolic acidosis depends on its severity. Patients with a serum bicarbonate level of less than 15 mEq/L and a pH of less than 7.20 are usually treated with intravenous sodium bicarbonate. The goal of treatment is to raise the pH to a value greater than 7.20. Rapid correction of the acidosis should be avoided, because tetany may occur as a result of hypocalcemia. Renal replacement therapies also may correct metabolic acidosis because it removes excess hydrogen ions and bicarbonate is added to the dialysate and replacement solutions; therefore, dialysis would not be cancelled. The tachypnea is a compensatory mechanism for the metabolic acidosis, and treatments to decrease the respiratory rate are not indicated. Treatment is aimed at correcting the metabolic acidosis, and this scenario does not provide data to support the need for intubation. DIF: Cognitive Level: Analysis REF: p. 450 OBJ: Describe the medical management of the patient with acute kidney injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The removal of plasma water and some low–molecular weight particles by using a pressure or osmotic gradient is known as: a. dialysis. b. diffusion. c. clearance. d. ultrafiltration. Ultrafiltration is the removal of plasma water and some low–molecular weight particles by using a pressure or osmotic gradient. Ultrafiltration is primarily aimed at controlling fluid volume, whereas dialysis is aimed at decreasing waste products and treating fluid and electrolyte imbalances. Diffusion (or clearance) is the movement of solutes such as urea from the patient’s blood to the dialysate cleansing fluid, across a semipermeable membrane (the hemofilter). DIF: Cognitive Level: Knowledge REF: p. 452 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for insertion of: a. a percutaneous catheter at the bedside. b. a percutaneous tunneled catheter at the bedside. c. an arteriovenous fistula. d. an arteriovenous graft. Temporary percutaneous catheters are commonly used in patients with acute kidney injury because they can be used immediately. Occasionally a percutaneous tunneled catheter is placed if the patient needs ongoing hemodialysis; however, these catheters are usually inserted in the operating room. An arteriovenous fistula is an internal, surgically created communication between an artery and a vein. This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use. Arteriovenous grafts are created by using different types of prosthetic material, most commonly polytetrafluoroethylene and Teflon. Grafts are placed under the skin and are surgically anastomosed between an artery and a vein. The graft site usually heals within 2 to 4 weeks. DIF: Cognitive Level: Application REF: p. 452 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should: a. prepare to assist with a routine dialysis catheter change to replace the existing catheter. b. evaluate the patient for signs and symptoms of infection. c. teach the patient that the catheter is designed for long-term use. d. use one of the three lumens for fluid administration. Routine replacement of hemodialysis catheters to prevent infection is not recommended. The decision to remove or replace the catheter is based on clinical need and/or signs and symptoms of infection. The typical catheter has a single or double lumen and is designed only for short-term renal replacement therapy during acute situations. The catheter is not used for fluid and medication administration. DIF: Cognitive Level: Application REF: p. 452 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. The patient has just returned from having an arteriovenous fistula placed. The patient asks, “When will they be able to use this and take this other catheter out?” The nurse should reply, a. “It can be used immediately so the catheter can come out anytime.” b. “It will take 2 to 4 weeks to heal before it can be used.” c. “The fistula will be usable in about 4 to 6 weeks.” d. “The fistula was made using graft material so it depends on the manufacturer.” An arteriovenous fistula is an internal, surgically created communication between an artery and a vein. This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use. DIF: Cognitive Level: Comprehension REF: pp. 452-453 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. The patient is in progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should: a. draw blood from the left arm. b. take blood pressures from the left arm. c. start a new intravenous line in the left lower arm. d. auscultate the left arm for a bruit and palpate for a thrill. An arteriovenous fistula should be auscultated for a bruit and palpated for the presence of a thrill or buzz every 8 hours. The extremity that has a fistula or graft must never be used for drawing blood specimens, obtaining blood pressure measurements, administering intravenous therapy, or giving intramuscular injections. Such activities produce pressure changes within the altered vessels that could result in clotting or rupture. DIF: Cognitive Level: Application REF: p. 453 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should: a. reassess the patient in an hour. b. raise the arm above the level of the patient’s heart. c. notify the provider immediately. d. apply warm packs to the fistula site and reassess. Inadequate collateral circulation past the fistula or graft may result in loss of this pulse. The physician is notified immediately if no bruit is auscultated, no thrill is palpated, or the distal pulse is absent. Loss of bruit and thrill indicate a loss of blood flow most likely due to clotting. The patient will need to return to surgery as soon as possible for declotting. Raising the arm above the level of the heart will not help. Warm packs may or may not help. DIF: Cognitive Level: Application REF: p. 453 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should: a. apply a sterile gauze dressing to maintain sterility. b. replace the transparent dressing every 10 days to prevent manipulation. c. assess the catheter site for redness and/or swelling. d. use the catheter for drawing blood samples to reduce patient discomfort. Tenderness at the insertion site, swelling, erythema or drainage should be reported to the physician. Transparent, semipermeable polyurethane dressings are recommended as they allow continuous visualization for assessment of signs of infection. Replace transparent dressings on temporary percutaneous catheters at least every 7 days and no more than once a week for tunneled percutaneous catheters unless the dressing is soiled or loose. The catheter is not used for the administration of fluids or medications or for the sampling of blood unless a specific order is obtained to do so. DIF: Cognitive Level: Application REF: p. 453 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 34. The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of: a. dialyzer membrane incompatibility. b. a shift in potassium levels. c. dialysis disequilibrium syndrome. d. hypothermia. Dialysis disequilibrium syndrome often occurs after the first or second dialysis treatment or in patients who have had sudden, large decreases in BUN and creatinine levels as a result of the hemodialysis. Because of the blood-brain barrier, dialysis does not deplete the concentrations of BUN, creatinine, and other uremic toxins in the brain as rapidly as it does those substances in the extracellular fluid. An osmotic concentration gradient established in the brain allows fluid to enter until the concentration levels equal those of the extracellular fluid. The extra fluid in the brain tissue creates a state of cerebral edema for the patient, which results in severe headaches, nausea and vomiting, twitching, mental confusion, and occasionally seizures. Dialyzer membrane incompatibility may cause hypotension. Hyperthermia, not hypothermia, may result if the temperature control devices on the dialysis machine malfunction. Potassium shifts may occur but would be manifested in cardiac dysrhythmias. DIF: Cognitive Level: Analysis REF: p. 453 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that: a. a hemofilter is used to facilitate ultrafiltration. b. it provides faster removal of solute and water. c. it does not allow diffusion to occur. d. the process removes solutes and water slowly. CRRT is a continuous extracorporeal blood purification system managed by the bedside critical care nurse. It is similar to conventional intermittent hemodialysis in that a hemofilter is used to facilitate the processes of ultrafiltration and diffusion. It differs in that CRRT provides a slow removal of solutes and water as compared to the rapid removal of water and solutes that occurs with intermittent hemodialysis. DIF: Cognitive Level: Comprehension REF: p. 454 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36. Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used to: a. remove plasma water in cases of volume overload. b. remove fluids and solutes through the process of convection. c. remove plasma water and solutes by adding dialysate. d. combine ultrafiltration, convection and dialysis. Slow continuous ultrafiltration (SCUF) is also known as isolated ultrafiltration and is used to remove plasma water in cases of volume overload. Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection. Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion. Continuous venovenous hemodiafiltration (CVVHDF) combines ultrafiltration, convection, and dialysis to maximize fluid and solute removal. DIF: Cognitive Level: Comprehension REF: p. 454 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 37. Continuous venovenous hemofiltration is used to: a. remove fluids and solutes through the process of convection. b. remove plasma water in cases of volume overload. c. remove plasma water and solutes by adding dialysate. d. combine ultrafiltration, convection and dialysis. Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection. Slow continuous ultrafiltration (SCUF) is used to remove plasma water in cases of volume overload. Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion. Continuous venovenous hemodiafiltration (CVVHDF) combines ultrafiltration, convection, and dialysis to maximize fluid and solute removal. DIF: Cognitive Level: Comprehension REF: p. 454 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 38. Continuous venovenous hemodialysis is used to: a. remove fluids and solutes through the process of convection. b. remove plasma water in cases of volume overload. c. remove plasma water and solutes by adding dialysate. d. combine ultrafiltration, convection and dialysis Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion. Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection. Slow continuous ultrafiltration (SCUF) is also known as isolated ultrafiltration and is used to remove plasma water in cases of volume overload. Continuous venovenous hemodiafiltration (CVVHDF) combines ultrafiltration, convection and dialysis to maximize fluid and solute removal. DIF: Cognitive Level: Comprehension REF: pp. 454-455 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should: a. assess that the blood tubing is warm to the touch. b. assess the hemofilter every 6 hours for clotting. c. cover the dialysis lines to protect them from light. d. use clean technique during vascular access dressing changes. The critical care nurse is responsible for monitoring the patient receiving CRRT. The hemofilter is assessed every 2 to 4 hours for clotting (as evidenced by dark fibers or a rapid decrease in the amount of ultrafiltration without a change in the patient’s hemodynamic status). The CRRT system is frequently assessed to ensure filter and lines are visible at all times, kinks are avoided, and the blood tubing is warm to the touch. The ultrafiltrate is assessed for blood (pink-tinged to frank blood), which is indicative of membrane rupture. Sterile technique is performed during vascular access dressing changes. DIF: Cognitive Level: Application REF: pp. 456-457 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 40. Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis: a. is more frequently used for acute kidney injury. b. uses the patient’s own semipermeable membrane (peritoneal membrane). c. is not useful in cases of drug overdose or electrolyte imbalance. d. is not indicated in cases of water intoxication. Peritoneal dialysis is the removal of solutes and fluid by diffusion through a patient’s own semipermeable membrane (the peritoneal membrane) with a dialysate solution that has been instilled into the peritoneal cavity. This renal replacement therapy is not commonly used for the treatment of acute kidney injury because of its comparatively slow ability to alter biochemical imbalances. Clinical indications for peritoneal dialysis include acute and chronic kidney injury, severe water intoxication, electrolyte disorders, and drug overdose. DIF: Cognitive Level: Comprehension REF: pp. 456-457 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Analysis MSC: NCLEX: Physiological Integrity 41. An advantage of peritoneal dialysis is that: a. peritoneal dialysis is time intensive. b. a decreased risk of peritonitis exists. c. biochemical disturbances are corrected rapidly. d. the danger of hemorrhage is minimal. Advantages of peritoneal dialysis include that the equipment is assembled easily and rapidly, the cost is relatively inexpensive, the danger of acute electrolyte imbalances or hemorrhage is minimal, and dialysate solutions can be individualized. In addition, automated peritoneal dialysis systems are available. Disadvantages of peritoneal dialysis include that it is time intensive, requiring at least 36 hours for a therapeutic effect to be achieved; biochemical disturbances are corrected slowly; access to the peritoneal cavity is sometimes difficult; and the risk of peritonitis is high. DIF: Cognitive Level: Comprehension REF: p. 457 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Analysis MSC: NCLEX: Physiological Integrity 42. The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient’s temperature is elevated. The nurse should: a. assess peritoneal dialysate return. b. check the patient’s blood sugar. c. evaluate the patient’s neurological status. d. inform the provider of probable visceral perforation. Peritonitis is the most common complication of peritoneal dialysis therapy and is usually caused by contamination in the system. Peritonitis is manifested by abdominal pain, cloudy peritoneal fluid, fever and chills, nausea and vomiting, and difficulty in draining fluid from the peritoneal cavity. DIF: Cognitive Level: Analysis REF: p. 457 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 43. The patient is on intake and output (I&O) as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should: a. draw a trough level after the next dose of antibiotic. b. obtain an order to place the patient on fluid restriction. c. assess the patient’s lungs. d. insert an indwelling catheter. The scenario indicates retention of fluid; therefore, the nurse must assess for symptoms of fluid overload, for example, by auscultating the lung fields. Adequate hydration is essential and fluid restriction would be determined by the physician upon physical examination and analysis of laboratory results. An indwelling urinary catheter should not routinely be inserted because it increases the risk of infection. A trough level is drawn just before the next dose of a drug is given and is an indicator of how the body has cleared the drug; it would not be done secondary to imbalanced intake and output. DIF: Cognitive Level: Application REF: p. 446 OBJ: Describe the medical management of the patient with acute kidney injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 44. The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. His blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; he has not voided in 8 hours and his bladder is not distended. The nurse anticipates an order for “stat” administration of: a. a blood transfusion. b. fluid replacement with 0.45% saline. c. infusion of an inotropic agent. d. an antiemetic. This scenario indicates hypovolemia from the nausea and vomiting, requiring volume replacement. Hypovolemia resulting from large urine or gastrointestinal losses often requires the administration of a hypotonic solution, such as 0.45% saline. Blood products would be indicated only in the presence of bleeding following assessment of hemoglobin and hematocrit levels. The inotrope is contraindicated in the presence of volume depletion. An antiemetic may be needed; however, the priority to prevent shock and acute kidney injury is fluid administration. DIF: Cognitive Level: Analysis REF: p. 440 OBJ: Describe the medical management of the patient with acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Identify which substances would indicate a problem with renal function. (Select all that apply). a. protein. b. sodium. c. creatinine. d. red blood cells. e. uric acid. , D, E The glomerular capillary membrane is approximately 100 times more permeable than other capillaries. It acts as a high-efficiency sieve and normally allows only substances with a certain molecular weight to cross. Normal glomerular filtrate is basically protein free and contains electrolytes, including sodium, chloride, and phosphate, and nitrogenous waste products, such as creatinine, urea, and uric acid, in amounts similar to those in plasma.Red blood cells, albumin, and globulin are too large to pass through the healthy glomerular membrane. DIF: Cognitive Level: Knowledge REF: p. 433 OBJ: Review the anatomy and physiology of the renal system. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.) a. bladder catheterization. b. increasing fluid volume intake. c. ureteral stenting. d. placement of nephrostomy tubes. e. increasing cardiac output. , C, D The location of the obstruction in the urinary tract determines the method by which the obstruction is treated and may include bladder catheterization, ureteral stenting, or the placement of nephrostomy tubes. Fluid volume intake may be recommended to treat prerenal causes of AKI. Increasing cardiac output would be indicated in certain prerenal causes of AKI. DIF: Cognitive Level: Knowledge REF: pp. 436-437 OBJ: Review the anatomy and physiology of the renal system. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Noninvasive diagnostic procedures used to determine kidney function include which of the following? (Select all that apply.) a. Kidney, ureter, bladder (KUB) x-ray b. Renal ultrasound c. Magnetic resonance imaging (MRI) d. Intravenous pyelography (IVP) e. Renal angiography , B, C Noninvasive diagnostic procedures are usually performed before any invasive diagnostic procedures are conducted. Noninvasive diagnostic procedures that assess the renal system are radiography of the kidneys, ureters, and bladder (KUB); renal ultrasonography; and magnetic resonance imaging. Invasive diagnostic procedures for assessing the renal system include intravenous pyelography, computed tomography, renal angiography, renal scanning, and renal biopsy. DIF: Cognitive Level: Knowledge REF: p. 444 OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of laboratory values and radiological diagnostic tests. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.) a. Acidosis b. Hypokalemia c. Volume overload d. Hyperkalemia e. Uremia , C, D, E The most common reasons for initiating dialysis in acute kidney injury include acidosis, hyperkalemia, volume overload, and uremia. Dialysis is usually started early in the course of the renal dysfunction before uremic complications occur. In addition, dialysis may be started for fluid management when total parenteral nutrition is administered. DIF: Cognitive Level: Knowledge REF: p. 452 OBJ: Describe the medical management of the patient with acute kidney injury. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.) a. Hypotension b. Dysrhythmias c. Muscle cramps d. Hemolysis e. Air embolism , B Hypotension is common and is usually the result of preexisting hypovolemia, excessive amounts of fluid removal, or excessively rapid removal of fluid. Dysrhythmias may occur during dialysis. Causes of dysrhythmias include a rapid shift in the serum potassium level, clearance of antidysrhythmic medications, preexisting coronary artery disease, hypoxemia, or hypercalcemia from rapid influx of calcium from the dialysate solution. Muscle cramps occur more commonly in chronic renal failure. Hemolysis, air embolism, and hyperthermia are rare complications of hemodialysis. DIF: Cognitive Level: Knowledge REF: p. 453 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The patient is in the critical care unit and will receive dialysis this morning. The nurse will: (Select all that apply.) a. evaluate morning laboratory results and report abnormal results. b. administer the patient’s antihypertensive medications. c. assess the dialysis access site and report abnormalities. d. weigh the patient to monitor fluid status. e. give all medications except for antihypertensive medications. , C, D The patient receiving hemodialysis requires specialized monitoring and interventions by the critical care nurse. Laboratory values are monitored and abnormal results reported to the nephrologist and dialysis staff. The patient is weighed daily to monitor fluid status. On the day of dialysis, dialyzable (water-soluble) medications are not given until after treatment. The dialysis nurse or pharmacist can be consulted to determine which medications to withhold or administer. Supplemental doses are administered as ordered after dialysis. Administration of antihypertensive agents is avoided for 4 to 6 hours before treatment, if possible. Doses of other medications that lower blood pressure (narcotics, sedatives) are reduced, if possible. The percutaneous catheter, fistula, or graft is assessed frequently; unusual findings such as loss of bruit, redness, or drainage at the site must be reported. After dialysis, the patient is assessed for signs of bleeding, hypovolemia, and dialysis disequilibrium syndrome. [Show More]

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