Points Awarded 30.00

Points Missed 5.00

Percentage 85.7%

Etiology

End-stage renal disease (ESRD) is the last stage in the progressive clinical syndrome called

chronic kidney disease (CKD).

1.

What is the best description of CKD?

A) There are frequent exacerbations since half of all nephrons are damaged.

INCORRECT

Half of all nephrons are often damaged in acute renal failure. In CKD, about 90% of nephrons

are typically involved.

B) Condition has a rapid onset with frequent remissions.

INCORRECT

Acute renal failure has a rapid onset, but chronic kidney disease has a gradual onset, occurring

over months or years. Neither form of renal failure has frequent periods of remission.

C) It is a fatal disorder unless renal replacement therapy is received.

CORRECT

CKD is fatal unless some form of renal replacement therapy (dialysis or organ transplant) is

done, whereas acute renal failure has a good prognosis for the return of kidney function if

appropriate supportive care is provided during the acute period.

D) Symptoms are reversible with life long medication.

INCORRECT

Chronic kidney disease is progressive, irreversible kidney injury. Acute renal failure may be

reversible with adequate supportive care during the acute episode.

CKD is a disorder with a complex etiology involving many interrelated factors. Diabetes mellitus

is a known risk factor for renal failure.

2.

What additional information in Louellen's history may be related to the onset of ESRD?

A) Hysterectomy at age 35.

INCORRECT

This is not a risk factor for CKD.

B) Hypertension.

CORRECT

Hypertension is one of the primary causes of CKD. The vast majority of clients with CKD have

hypertension, which may be either the cause or the result of CKD.

C) Female gender.

INCORRECT

CKD does not seem to be more common in either gender.

D) Use of diuretics.

INCORRECT

Use of diuretics is not a cause of CKD, but obtaining a medication history is important since

many medications are nephrotoxic.

Diagnostic Evaluation

The following diagnostic tests were performed:

Hemoglobin.

Serum creatinine and BUN.

Serum calcium.

Arterial blood gases.

Serum potassium.

Serum phosphorus.

Urinary creatinine clearance.

3.

Which lab value is likely to be decreased in a client with chronic kidney disease?

A) Serum creatinine and BUN.

INCORRECT

Serum creatinine and BUN are tests which evaluate the removal of nitrogenous wastes by the

kidney. Both are increased in chronic kidney disease, although BUN levels are directly impacted

by protein intake, hydration status, and other factors.

B) Serum calcium.

CORRECT

Serum calcium is decreased in CKD in response to an increase in serum

phosphorous.

C) Serum phosphorous.

INCORRECT

Serum phosphorous is increased as less phosphorous is excreted by the kidney.

D) Serum potassium.

INCORRECT

Serum potassium levels are increased in CKD as the kidney loses the ability to remove

potassium from the body. Clients with CKD should be assessed carefully for symptoms of

hyperkalemia.

The nurse notes that Louellen's Hemoglobin level is 7.8.

4.

What is the underlying pathology causing this abnormal lab value?

A) Fewer red blood cells are being formed.

CORRECT

Hemoglobin is decreased as the kidneys become less able to produce erythropoietin necessary

for the formation of red blood cells.

B) Renal waste products destroy red blood cells.

INCORRECT

This does not occur.

C) Hematuria results in blood loss.

INCORRECT

CKD does not result in hematuria.

D) Dehydration causes dilutional anemia.

INCORRECT

If dehydration occurred, it would be more likely to result in a high hemoglobin level rather than a

low level.

Louellen's arterial blood gas (ABG) results are:

pH 7.35.

PO2 96.00 mmHg.

PCO2 30.00 mmHg.

HCO3 18.00 mEq/L.

5.

What is the correct interpretation of these ABGs?

A) Metabolic acidosis (compensated).

CORRECT

As excessive bicarbonate is excreted, the HCO3 level decreases, causing metabolic acidosis

(decreased pH). Compensation occurs when an increased rate and depth of respirations reduce

the CO2 levels, returning the pH to low normal.

B) Respiratory alkalosis (compensated).

INCORRECT

Alkalosis would be indicated by an increased pH rather than decreased pH.

C) Respiratory acidosis (compensated).

INCORRECT

This is a compensated acidosis, but if it were respiratory in nature, the CO2 would be elevated

rather than decreased.

D) Metabolic alkalosis (compensated).

INCORRECT

Alkalosis would be indicated by an increased pH rather than decreased pH.

Clinical Manifestations

Louellen's diagnostic tests confirm the medical diagnosis of end-stage renal disease. In addition

to Louellen's complaints of fatigue, anorexia, dyspnea, and nocturia, the nurse's assessment

findings include: +1 pedal edema, basilar crackles in both lungs, and clear, pale urine. Louellen's

VS are: T 98.8° F, P 86, R 28, and BP 178/92.

6.

Which additional assessment finding is consistent with ESRD?

A) Yellow-gray pallor.

CORRECT

The client with ESRD often exhibits a yellow-gray pallor as the result of anemia and uremia. In

addition, the client with ESRD may exhibit other skin manifestations such as bruising and

uremic frost (a very late manifestation).

B) Clay-colored stool.

INCORRECT

This is not a manifestation seen in ESRD.

C) Fingernail clubbing.

INCORRECT

This finding is typical in clients with chronic lung disorders, but not in ESRD.

D) Stridor.

INCORRECT

Stridor is a crowing respiratory noise due to bronchoconstriction. It is not an expected finding in

ESRD.

The nurse notes that Louellen's blood pressure is elevated.

7.

Which explanation best describes the pathology resulting in her hypertension?

A) Activation of the renin-angiotensin cycle and excretion of aldosterone causes

hypertension.

CORRECT

The renin-angiotensin cycle causes vasoconstriction of the periphery which increases the blood

pressure. In addition, the excretion of aldosterone causes the retention of sodium and water,

further increasing the fluid volume which increases the blood pressure.

B) Irritation of the pericardial lining of the heart due to uremic toxins increases blood

pressure.

INCORRECT

This explains the cause of pericarditis.

C) An increase in the excretion of sodium and water from the kidneys causes hypertension.

INCORRECT

Hypertension would be caused by an increase in the retention of sodium and water rather than an

increase in the excretion of sodium and water.

D) The increase of uremic waste products in the blood stream increases the blood pressure.

INCORRECT

This is the probable cause for gastrointestinal manifestations such as anorexia, nausea, and

vomiting.

Pharmacologic Management

Louellen receives prescriptions for the following medications:

Calcium acetate (Phoslo) 2 gelcaps (667 mg each) PO with each meal.

Ferrous sulfate (Feosol) 1 tablet PO (65 mg) daily.

Epoetin alfa (Epogen) 3900 units subcutaneously 3 times per week (dosed at 75 U/kg

three times a week).

Glipizide (Glucotrol) 10 mg PO daily - take 30 minutes before breakfast.

Furosemide (Lasix) 40 mg PO twice daily.

Captopril (Capoten) 25 mg PO twice daily.

Potassium chloride (Kay Ciel) elixir 40 mEq PO three times daily.

8.

Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate

(Phoslo) has been achieved?

A) Serum phosphorous of 4.0 mg/dl.

CORRECT

Calcium acetate (Phoslo) acts as a phosphate binder, reducing the high serum phosphorous levels

commonly found in the client with CKD.

B) Serum hematocrit of 32%.

INCORRECT

Hematocrit is not affected by the use of Phoslo.

C) Serum hemoglobin of 12 g/dl.

INCORRECT

Hemoglobin is not affected by the use of Phoslo.

D) Serum glucose of 90 mg/dl.

INCORRECT

This normal glucose level is managed with the client's glipizide (Glucotrol).

9.

Which assessment should the nurse perform to determine if the desired outcome of the captopril

(Capoten) has been achieved?

A) Fingerstick glucose.

INCORRECT

This would be an appropriate assessment measure for a hypoglycemic agent such as glipizide

(Glucotrol), but not for captopril.

B) Intake and output.

INCORRECT

This would be an appropriate assessment measure for a diuretic such as fuorsemide (Lasix), but

not for captopril.

C) Apical pulse.

INCORRECT

This does not provide data as to the desired outcome of the captopril.

D) Blood pressure.

CORRECT

Captopril (Capoten) is an ACE inhibitor used as an antihypertensive agent.

10.

Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa

(Epogen) has been achieved?

A) Normo-active bowel sounds.

INCORRECT

This is not an indicator for the desired outcome of Epogen.

B) Ate 100% of diet.

INCORRECT

This is not the BEST indicator that the desired outcome of Epoetin has been achieved, although

an improvement in dietary intake may be a secondary benefit of a reduction in fatigue.

C) No further edema.

INCORRECT

This assessment finding is an indicator used to assess the effectiveness of a diuretic such as

fuorsemide (Lasix), but not Epogen.

D) Conjunctival sac returns to a reddish-pink color.

CORRECT

This assessment finding reflects an improvement in the client's anemia. Epogen stimulates the

production of RBCs, resulting in an increase in hematocrit. It is used to treat the anemia common

in clients with CKD.

Nursing Diagnoses and Interventions

Louellen is admitted to an acute care facility for management of her ESRD. The nurse's plan of

care includes the following nursing diagnoses:

Fluid volume excess.

Altered nutrition: less than body requirements.

Decreased cardiac output.

Fatigue.

Constipation.

Risk for injury.

11.

Based on these diagnoses, which nursing intervention should be included in Louellen's plan of

care?

A) Monitor and record daily weights.

CORRECT

Daily weights are an essential assessment of the degree of fluid volume excess. Remember, 1 kg

of weight gain equals about 1 liter of retained fluid. The cornerstones of conservative

management of CKD are fluid restriction, diet therapy, and drug therapy.

B) Encourage oral fluid intake.

INCORRECT

Fluid restrictions will be instituted.

C) Avoid any subcutaneous and intramuscular injections.

INCORRECT

Although the client with CKD is likely to bruise easily due to a reduction in platelets, avoidance

of injections is not necessary.

D) Offer frequent high-protein snacks.

INCORRECT

Protein is restricted to reduce the accumulation of waste products associated with protein

metabolism, which causes the manifestations of uremia.

Louellen asks the nurse if she can eat eggs.

12.

The nurse's response is based on what understanding?

A) Eggs are considered an incomplete protein source.

INCORRECT

Eggs are considered a complete protein.

B) Eggs are a source of high biologic value protein.

CORRECT

Since protein intake is restricted, the protein allowed should be of high biologic value, such as

eggs.

C) Eggs are a high-fat food and should be avoided.

INCORRECT

Eggs are only high in fat if cooked in fat, such as when fried in oil or bacon grease.

D) Eggs contain too much protein and are not allowed.

INCORRECT

Eggs are a good source of protein.

Louellen has a urinary output of 120 ml for the previous 24 hours. She is on fluid restriction.

13.

How much fluid will Louellen be allowed to drink during the next 24 hours?

A) 1,000 ml of fluid.

INCORRECT

This is not the correct amount for Louellen.

B) 450 ml of fluid.

INCORRECT

This is not the correct amount for Louellen.

C) 20 ml of fluid.

INCORRECT

This is not the correct amount for Louellen.

D) 720 ml of fluid.

CORRECT

Usually the fluid allowance is 500 to 600 ml more than the previous day's 24-hour urine output.

Ethical/Legal Considerations: Medication Administration

The nurse notes that the prescribed medications include potassium chloride (Kay Ciel) elixir 40

mEq PO 3 times a day. Prior to administering the medication, the nurse monitors Louellen's

serum potassium level, which is 6.5 mmol/L.

14.

What is the best nursing intervention?

A) Ask the pharmacist to supply a tablet rather than an elixir since Louellen is on fluid

restriction.

INCORRECT

Because this requires a change in prescription, the health care provider must be contacted

regarding this change. Since the administration of this prescription would be unsafe for the client

in any form, there is another intervention that should be implemented.

B) Calculate the milliliters of medication needed and record the amount on the fluid intake

record.

INCORRECT

If the potassium level was within normal limits and the medication was to be given, this would

be an appropriate intervention. However, since the potassium level is high, this is not the correct

intervention.

C) Hold the dose of Kay Ciel and contact the health care provider to report the serum

potassium level.

CORRECT

The serum potassium level is elevated, and administering additional potassium in any form is

potentially dangerous to the client.

D) Administer the dose of Kay Ciel and document the serum potassium level in the medical

record.

INCORRECT

This is not an appropriate intervention considering the client's elevated serum potassium level.

The nurse reports the serum potassium level to the health care provider's office nurse, who calls

back and tells the nurse that the health care provider wants the dose of Kay Ciel reduced by half

and changed to an oral tablet, rather than an elixir.

15.

What intervention should the nurse implement?

A) Administer the prescribed tablet.

INCORRECT

This is an unsafe intervention since the client's serum potassium is elevated.

B) Request a faxed copy of the prescription.

INCORRECT

Requesting a written copy of a prescription is always desirable, but in this case will only confirm

an unsafe prescription.

C) Obtain the name of the office nurse.

INCORRECT

This is an appropriate action, but it is not the most important action at this time.

D) Ask to speak directly with the health care provider.

CORRECT

The medication prescription is unsafe and requires direct communication with the prescribing

health care provider.

The nurse consults with the health care provider, who becomes angry, and tells the nurse that

health care provider's orders should never be questioned.

16.

Which statement should serve as the basis for the nurse's reply?

A) Only the prescribing health care provider is legally liable for the administration of a

prescribed, but unsafe, medication.

INCORRECT

This is an inaccurate statement. Liability extends beyond the health care provider.

B) The RN job description in most hospital policy manuals clearly states that adhering to the

health care provider's prescriptions is required.

INCORRECT

The nurse must use sound professional judgment to determine if a prescribed medication or

treatment is safe, and should collaborate with the prescribing health care provider. In addition,

the nurse must be careful to act within the limitations of the state nurse practice act, and may not

administer a medication or medical treatment without a prescription.

C) State nurse practice acts indicate that the professional nurse should only administer legally

prescribed medications.

INCORRECT

The nurse practice act in each state does establish the legal regulation of the practice of nursing.

However, the issue in question is not the legality of the prescription, but rather, the safety of the

prescription.

D) The professional nurse can be held accountable for the administration of any unsafe

medication.

CORRECT

The professional nurse can be held legally liable for the administration of an unsafe medication.

Hemodialysis

Louellen's urinary output continues to diminish, and her lab values indicate worsening kidney

function. The health care provider and nurse discuss types of dialysis with Louellen. She must

consider the benefits and risks of both peritoneal dialysis and hemodialysis.

17.

Which factor is related to the use of hemodialysis?

A) Treatments require more time.

INCORRECT

Peritoneal dialysis typically requires a longer period of time for the exchange of fluid than does

hemodialysis.

B) High risk for air embolus.

CORRECT

The client with hemodialysis is at high risk for air embolus since vascular access is required.

C) More easily performed at home.

INCORRECT

Peritoneal dialysis is more easily performed at home because hemodialysis requires more

complex machinery and a treated water supply, and it is more likely to cause hemodynamic

instability.

D) High risk of abdominal infection.

INCORRECT

Peritoneal dialysis places the client at high risk for peritonitis since the catheter and fluid enter

the peritoneal cavity.

18.

Louellen is at increased risk for the development of which problem while receiving

hemodialysis?

A) Ascites.

INCORRECT

Ascites is not a potential complication of hemodialysis.

B) Hepatitis B and C.

CORRECT

Clients on hemodialysis are at greater risk for contracting hepatitis B and C than clients on

peritoneal dialysis because of the equipment used in hemodialysis. Hepatitis B vaccine is

encouraged for clients with chronic kidney disease.

C) Hypertension.

INCORRECT

The client is at risk for developing hypotension during treatment due to the fluid being removed.

Nausea, vomiting, diaphoresis, tachycardia, and dizziness are common signs of hypotension.

D) Blood clot formation.

INCORRECT

The client must be heparinized during hemodialysis. Therefore, bleeding is a more likely

potential complication than thrombosis.

Vascular Access Devices

Louellen decides that hemodialysis is the best choice for her. An arteriovenous (AV) graft is

surgically placed in her right forearm, and a dual-lumen hemodialysis catheter is placed for

temporary use until her permanent AV graft site heals.

19.

What is the best description of an AV graft?

A) Synthetic tubing tunneled beneath the skin connecting an artery and a vein.

CORRECT

These grafts can be placed in the arm or inner thigh and can be used within 1 to 2 weeks of

surgery.

B) Internal surgical anastomosis between an artery and a vein.

INCORRECT

This describes an AV fistula, typically located in the forearm. AV fistulas require prolonged

healing (2 to 4 months) before use.

C) External loop of synthetic tubing connecting an artery and a vein.

INCORRECT

This describes an AV shunt. Shunts can be used immediately after insertion, but since the advent

of central line catheters, shunts are no longer commonly used.

D) Central line tunneled catheter with a barrier cuff.

INCORRECT

This describes a soft flexible catheter that is tunneled under the skin and placed in the superior

vena cava. The cuff keeps the catheter in place and serves as a barrier to infection.

While assessing Louellen's AV graft site, the nurse palpates a buzzing sensation directly over the

graft.

20.

Which documentation should the nurse enter into the nurses' notes?

A) Thrill present and palpated.

CORRECT

This buzzing sensation indicates that the graft is patent. In addition to palpating for a thrill, the

nurse should auscultate for a bruit, the sound heard at a patent graft site, as well as for intact

pulses distal to the graft site.

B) Health care provider notified of graft occlusion.

INCORRECT

A palpable thrill and audible (with stethoscope) bruit over the graft site indicate that the graft is

patent. The nurse should also assess the pulse distal to the graft site to ensure adequate

circulation.

C) Bruit intact and palpated.

INCORRECT

A bruit is the swishing sound heard when the graft site is auscultated. This should also be

assessed when the graft is palpated.

D) +4 bounding pulse palpated.

INCORRECT

This sensation does not reflect the client's pulse, although it is important for the nurse to assess

the pulse distal to the graft.

21.

Which intervention should the nurse include in Louellen's plan of care?

A) Regularly rotate IV insertion sites above and below the graft site.

INCORRECT

The extremity with the graft should not be used for venipuncture (starting IVs or drawing blood)

or for blood pressure assessment.

B) Empty and record the drainage from the graft tubing regularly.

INCORRECT

The graft tubing is internal, and there is no attached external drainage device. The surgical site

should be assessed for bleeding.

C) Perform sterile dressing changes at the dual-lumen catheter site.

CORRECT

Central vein insertion sites are major sources of nosocomial infection, and they should be

cleaned weekly using a strict aseptic technique.

D) Instruct lab personnel to obtain blood specimens from the dual-lumen catheter.

INCORRECT

This is not a safe intervention. Hemodialysis catheters are heparinized following dialysis

treatments to prevent catheter thrombosis, and they require the removal of this heparinized

solution using a strict aseptic technique. Use of these catheters between treatments for

medication administration or blood samples is not advised due to the high risk for complications.

Client Teaching: Dietary Management

Louellen is tolerating dialysis well, and she is scheduled for discharge. The nurse completes

discharge teaching for the goal, "Client will manage her diet effectively while receiving

hemodialysis 3 times a week."

22.

Which expected outcome should be included in the nurse's teaching plan?

A) Client will identify the need to increase her sodium and fluid intake.

INCORRECT

The client receiving hemodialysis will more typically need to restrict sodium and fluid intake,

rather than increase the amounts consumed.

B) Client will identify the need to avoid fresh fruits and vegetables.

INCORRECT

Because fresh fruits and vegetables provide much needed vitamins, they do not need to be

avoided. However, those fruits that are high in potassium should not be eaten in excessive

amounts.

C) Client will select foods high in iron and calcium from a menu.

CORRECT

Clients with CKD are frequently anemic and hypocalcemic, requiring dietary supplementation

with iron and calcium.

D) Client will adhere to a high-protein diet.

INCORRECT

Clients on hemodialysis must frequently restrict protein intake. The client's BUN is monitored to

ensure protein intake is sufficient, but not excessive.

23.

What is the maximum amount of weight that Louellen should gain between each dialysis

treatment?

A) 2 kg of weight.

INCORRECT

This is not the correct amount of weight.

B) 1.5 kg of weight.

CORRECT

The goal for hemodialysis clients is to keep their interdialytic (between dialysis treatments)

weight gain under 1.5 kg.

C) 2.5 kg of weight.

INCORRECT

This is not the correct amount of weight.

D) 3 kg of weight.

INCORRECT

This is not the correct amount of weight.

Kidney Transplantation

After receiving hemodialysis for about a year, Louellen is scheduled to receive a kidney

transplant from her older brother. Following surgery, Louellen is transferred to the Surgical

Intensive Care Unit. She is drowsy but awakens easily. She is able to swallow sips of water. Her

incision is clean, dry, and intact.

24.

Which nursing assessment has the highest priority during the first 24-hour postoperative period?

A) Range of motion.

INCORRECT

Although an important assessment parameter, range of motion is not the highest priority.

B) Vital signs.

CORRECT

Vital signs should be monitored frequently to assess for postoperative bleeding, infection, or

organ rejection.

C) Bowel sounds.

INCORRECT

Although an important assessment parameter, the return of bowel sounds in the first 24 hours is

not the highest priority.

D) Pedal pulses.

INCORRECT

Although an important assessment parameter, pedal pulses are not the highest priority.

25.

Which intervention should be included in the plan of care during the immediate postoperative

period?

A) Encourage Louellen to use the incentive spirometer daily.

INCORRECT

Louellen should use the incentive spriometer at least every 2-4 hours to prevent complications

from immobility such as pneumonia.

B) Monitor Louellen's nasogastric tube every 4 hours.

INCORRECT

The client usually does not have a nasogastric tube in place after this surgery. If one is present, it

should be monitored more frequently than every 4 hours.

C) Monitor Louellen's urinary output hourly using an urimeter.

CORRECT

A kidney from a living donor related to the client usually begins to function immediately after

surgery and may produce large amounts of dilute urine. Therefore, the output should be closely

monitored.

D) Assess Louellen's surgical incision every shift.

INCORRECT

The surgical incision should be assessed at least every 2 hours in the immediate postoperative

period.

Immunosuppressive Agents

Louellen's postoperative medications include immunosuppressive agents, which are used to

reduce the risk of organ rejection.

Azathioprine (Imuran) 3 mg/kg IV daily.

Cyclosporine (Sandimmune) 4 mg/kg IV daily.

Solu-Medrol 60 mg IV every 6 hours.

26.

The nursing is preparing to give Louellen’s medications. The cyclosporine (Sandimmune) comes

in a vial with 50 mg/ml. Louellen weighs 132 lbs. How many milliliters of the medication should

the nurse draw up? (Enter numerical value only. If rounding is necessary, round to the whole

number.) 5

CORRECT

D/H x V = X

132 lbs./2.2 lbs per kg = 60 kg

60 kg x 4 mg/kg = 120 mg

120 mg x 1 ml/50 mg = 4.8 ml

27.

Which nursing diagnosis has the greatest priority when caring for a client receiving

immunosuppressive agents?

A) Risk for infection.

CORRECT

Suppression of the normal immune response causes leukopenia that can reduce the client's ability

to fight infection, resulting in the potential for life-threatening sepsis.

B) Fatigue.

INCORRECT

Immunosuppressive agents can cause fatigue, but this is not the highest priority.

C) Pain.

INCORRECT

Immunosuppressive agents such as Imuran can cause arthralgia, but this is not the highest

priority.

D) Diarrhea.

INCORRECT

Immunosuppressive agents such as cyclosporine can cause diarrhea, but this is not the highest

priority.

28.

Which interventions are important to include in Louellen's plan of care while she is receiving

multiple immunosuppressants? (Select all that apply. To proceed, de-select any incorrect

answer(s) and try again.)

A) Change the IV site daily.

INCORRECT

Although the IV site should be monitored frequently for signs of phlebitis and infection, IV site

changes should be performed following CDC guidelines. Excessive IV starts can be a source of

infection.

B) Have all staff and visitors wash their hands every time they enter her room.

CORRECT

Handwashing is one of the best ways to prevent the spread of infection.

C) Reinforce, but do not routinely change any dressings.

INCORRECT

Dressings should be changed regularly, which allows inspection of the wound for signs of

infection. Strict aseptic technique should be used to reduce the risk of infection.

D) Restrict Louellen's activity to bedrest with use of the bedside commode.

INCORRECT

Since Louellen is at high risk for infection, activity and mobility should be encouraged to prevent

the complications of immobility, such as atelectasis and pneumonia. Louellen should be assisted

with mobility as needed since she is also at risk for injury.

E) Instruct visitors that fresh flowers should not be taken into the room.

CORRECT

Fresh flowers, plants, and fruits are a source of bacteria and should be restricted from the client's

room. In addition, visitors should be restricted to healthy adults, and extra precautions should be

taken to avoid sharing hospital equipment and to ensure a clean room environment.

Management Issues: Priorities & Delegation

When Louellen is transferred from the Surgical Intensive Care Unit (SICU) back to the Surgical

Nursing Care Unit, the nurse receives report on her condition. The report includes information

that Louellen's IV needs to be converted to a saline lock and that her urinary catheter needs to be

removed. During the nursing assessment, Louellen reports that she is experiencing incisional

pain from all the activity and that the tape on her surgical dressing became loose during the

transfer.

29.

Which action should the nurse implement first?

A) Change the surgical dressing.

INCORRECT

Since only the tape is loose, this is not the highest priority intervention.

B) Remove the indwelling catheter.

INCORRECT

This action is a low priority and one that can increase the client's discomfort temporarily as the

catheter is pulled from the bladder. It should be deferred until the client's higher priority need has

been addressed.

C) Administer an analgesic.

CORRECT

This intervention will reduce the client's pain and anxiety. It will also reduce discomfort when

other procedures such as a dressing change are performed.

D) Convert the IV to a saline lock.

INCORRECT

Converting the IV to a saline lock is a low priority at this time.

30.

Which action can be delegated to the unlicensed assistive personnel (UAP)?

A) Change the surgical dressing.

INCORRECT

UAPs do not routinely change surgical dressings since this skill requires the expertise of the

nurse.

B) Administer an analgesic.

INCORRECT

UAPs do not administer medications.

C) Convert the IV to a saline lock.

INCORRECT

This is a procedure requiring knowledge and skills beyond the scope of practice of a UAP.

D) Remove the indwelling catheter.

CORRECT

This task may be delegated to the UAP since it is not an invasive procedure requiring the

expertise of the nurse.

A Complication Occurs

One week after surgery, Louellen is discharged home. Three days later, she calls the nurse to

report that she is experiencing more pain than she thinks she should be having.

31.

What is the best initial response by the nurse?

A) "The health care provider will need to call you back later if you need more pain

medication."

INCORRECT

The nurse first needs to obtain additional information.

B) "You may have developed a tolerance to your pain medication."

INCORRECT

This is not the best response, since the nurse has not obtained adequate data to make this

determination.

C) "Describe the location and type of pain you are having."

CORRECT

The nurse needs to obtain additional data to help determine the nature of the problem.

D) "Going home often causes anxiety, which can increase your pain."

INCORRECT

This is not the best response since the nurse has not obtained adequate data to make this

determination.

In response to the nurse's questions, Louellen states she feels very sore over her kidney area and

she cannot remember voiding in the last 24 hours.

32.

Which instructions should the nurse give Louellen?

A) Increase her fluid intake and report any increase in her weight.

INCORRECT

These interventions do not address Louellen's symptoms.

B) Monitor her temperature and report a fever over 101° F.

INCORRECT

The presence of a fever requires further investigation by the nurse because it can be a symptom

of both infection and rejection, which are treated very differently.

C) Advise her to come to the clinic right away for further evaluation.

CORRECT

Louellen is exhibiting symptoms consistent with organ rejection. She needs immediate

assessment and evaluation for this potentially fatal complication. The nurse should assess for

kidney pain, oliguria or anuria, hypertension, lethargy, fever, and fluid retention, as well as

increased serum BUN, creatinine, and potassium.

D) Take her prescribed diuretic and analgesic and record when she voids.

INCORRECT

Louellen is exhibiting symptoms that require a different intervention.

Therapeutic Communication: Grief Response

Louellen returns to the clinic, where her vital signs are: T 100.6° F, P 88, R 24, BP 178/96. A

renal scan is performed, and it is determined that Louellen is experiencing acute organ rejection.

Three types of rejection can occur after transplant: hyperacute, acute, and chronic.

Hyperacute rejection occurs within the first 48 hours after transplantation and requires

immediate removal of the transplanted kidney.

Acute rejection occurs up to 2 years after surgery, most commonly within the first 2

weeks. It can often be managed effectively with increased doses of immunosuppressive

medications.

Chronic rejection is a gradual process, occurring over a period of months to years.

Conservative management, including a careful balance of fluid and protein intake helps

control the rejection, but the eventual outcome is the need for dialysis.

Louellen is started on a regimen of high-dose immunosupressants.

During the acute rejection period, Louellen's brother states to the nurse, "She can't be having a

rejection; I gave up my kidney for her. The doctors must have messed up something. I'll sue

every one of them if this doesn't work."

33.

What is the best response by the nurse?

A) "Your obvious anger will not help Louellen now."

INCORRECT

Admonishing Louellen's brother is a block to further communication.

B) "Don't blame the health care providers. They're doing everything possible."

INCORRECT

Giving advice is a block to further communication.

C) "This is a very difficult time for you and your family."

CORRECT

Acknowledgment of the stress being experienced will encourage the brother to continue to

express his feelings.

D) "Why do you think the health care providers are at fault?"

INCORRECT

Asking "why" places the brother on the defensive and is a block to further communication.

The nurse recognizes that Louellen's brother is grieving. Stages in the grief process include

denial, anger, bargaining, depression, and acceptance. The nurse can offer support and

encouragement during each of these stages. Louellen's brother is experiencing anger.

34.

What action should the nurse implement?

A) Reassure the brother that this stage of grieving will end soon.

INCORRECT

This may be false reassurance. Some individuals remain in a stage of grief for prolonged periods

of time.

B) Encourage the expression of anger in a non-harmful manner.

CORRECT

Anger is a normal, healthy response to loss. The nurse should help the brother find a way to

express his anger that is not harmful to himself or others. Avoiding the expression of anger may

result in the anger turning inward, causing depression or self-harm.

C) Instruct the brother to avoid expressing feelings of anger to others.

INCORRECT

This is not the best recommendation concerning anger.

D) Remind the brother that anger is damaging and unhealthy.

INCORRECT

While this is true, it will not help the client's brother and can close communication channels.

Case Outcome

Louellen's brother is able to share his frustration and anger with other family members. He

physically vents his anger by tearing down an old fence.

The medical regimen of immunosuppressants is successful in reversing the organ rejection, and

Louellen is discharged home with the support of her family and the home care nursing agency.