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The nurse reviews the client's medical history. What part of the medical history should the nurse consider relevant to the client's current history? (Select all that apply. One, some, or all options may be correct.)
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Which additional symptoms should the nurse ask about? (Select all that apply. One, some, or all options may be correct.)
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HESI REMEDIATION 246
| Question | Answer |
|---|---|
| The nurse reviews the client's medical history. What part of the medical history should the nurse consider relevant to the client's current history? (Select all that apply. One, some, or all options may be correct.) | - Hypertension - Polycystic kidney disease - Diabetes Mellitus- |
| Which additional symptoms should the nurse ask about? (Select all that apply. One, some, or all options may be correct.) | - Nausea - Decreased attention span - Itching |
| Based on the client's symptoms, what should the nurse suspect? | The client has uremia and may need to start dialysis. |
| The nurse is teaching the client about progression of chronic kidney disease (CKD). Which evaluation statement documented by the nurse indicates the client's understanding of the disease process? | The client acknowledges that renal replacement therapy will need to be initiated immediately to rid the body of waste and maintain fluid balance. |
| Which lab value would the nurse be MOST concerned about? | Glomerular filtration rate (GFR) of 9mL/min/1.73m2. |
| What is the correct interpretation of these ABG's? | Metabolic acidosis (compensated) |
| What assessment data supports the diagnosis of acute organ rejection? (Select all that apply. One, some, or all options may be correct.) | - Blood pressure of 178/96 mm Hg. - Sub therapeutic immunosuppression levels - Acute pain rated 6/10 - Temperature of 100.6 F(38.1 C). - BUN of 56 mg/dL (19.99 mmol/L) and Creatinine of 1.9 mg/dL (167.96 mcmol/L |
| The client's hemoglobin level is 7.8 g/dL (78 g/L). What action should the nurse take? | Obtain an order to start an erythropoietin stimulating agent (ESA) |
| After the nurse completes the assessment, what findings are most important to report to the healthcare provider (HCP) ? (Select all that apply. One, some, or all options may be correct.) | - Blood pressure of 178/92 mmHg - Respiratory rate of 28 breaths per minute- Bibasilar crackles - Edema |
| Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate has been achieved? | Serum phosphorous of 4.0 mg/dL (1.29 mmol/L)5 |
| Which assessment should the nurse perform to determine if the desired outcome of the losartan has been achieved? | Blood pressure |
| Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa has been achieved? | Conjunctival sac returns to a reddish pink color |
| Based on these problems, which nursing intervention should be included in the client's plan of care? | Encourage the client to ask questions and discuss fears about diagnosis |
| Which intervention is most important for the nurse to implement? | Hold the dose of potassium chloride and contact the HCP to report the serum potassium level. |
| Which intervention should the nurse implement? | Call and speak directly with the healthcare provider (HCP). |
| What action should the nurse take based on the response from the healthcare provider (HCP) phone call? (Select all that apply. One, some, or all options may be correct.) | Document both phone calls and the HCP's prescriptions. - Notify the charge nurse and activate the chain of command - Hold the potassium chloride |
| The nurse prepares and instructs the client for hemodialysis. Which statements by the client indicate the need for further education? (Select all that apply. One, some, or all options may be correct.) | Hemodialysis will help restore kidney function back to a normal level. - Bowel or bladder perforation may occur with hemodialysis catheter placement. |
| What complication would the client be most concerned about if choosing peritoneal dialysis? | Abdominal infection/Peritonitis |
| The client asks the nurse to clarify what palliative care involves. Which explanation provides the client the best education regarding palliative care? (Select all that apply. One, some, or all options may be correct.) | Palliative care provides relief from symptoms including pain. - Palliative care supports holistic care and improves quality of life. - |
| The nurse documents the assessment of the arteriovenous (AV) graft. Which documentation best describes a properly functioning AV graft? | Thrill present and palpated |
| Which intervention should the nurse ensure has been include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.) | Perform sterile dressing changes at the dual lumen catheter site - Assess the client's distal pulses and circulation in the arm with the access. |
| The nurse assesses the dialysis graft. Which assessment should be reported to the healthcare provider (HCP) immediately? (Select all that apply. One, some, or all options may be correct.) | Yellow, purulent drainage from graft incision site. - Absence of a thrill over the graft site. - Capillary refill >10 seconds in the hand where the graft is placed. |
| Which expected outcome should be included in the nurse's teaching plan? | Client will avoid canned and processed foods. |
| The nurse is teaching the patient about fluid management between dialysis treatments. Which instruction by the nurse is the most accurate? | Limit fluids in between treatments to minimize the amount of fluid that needs to be removed during dialysis. |
| Which is the priority nursing assessment during the first 24-hour postoperative period? | Vital signs |
| Which intervention should the nurse ensure is included in the plan of care during the immediate postoperative period? | Monitor the client's urinary output hourly using an urimeter. |
| The nurse is preparing....The anti-thymocyte globulin (ATG) comes in a vial with 25mg/10mL. the client weighs 132 lbs (60 kg). The Thymoglobulin will be infused over 6 hours. What rate should the nurse program on the infusion pump? | 60 kg x 4.5 mg =270 mg 270 mg/ 25 mg x 10 mL =108 mL / 6 hours = 18 mL per hour |
| Which interventions are important to include in the client's plan of care while receiving multiple immunosuppressants? (Select all that apply. One, some, or all options may be correct.) | Instruct client to wear a mask when walking in the halls. - Instruct visitors that fresh flowers should not be taken into the room. - Monitor immunosuppression drug levels regularly. |
| Which action should the nurse implement first? | Administer an analgesic. |
| Based on the nurse's assessment, which assessment data supports the decision to administer pain medication as the first intervention? (Select all that apply. One, some, or all options may be correct.) | Pain rating of 6/10 - Heart rate of 102 beats/minute - Blood pressure of 132/76 mmHg |
| Which action can be assigned to the unlicensed assistive personnel (UAP)? | Measure the client's urinary output. |
| What is the best initial response by the nurse? | Describe the location and type of pain you are having |
| Which instructions should the nurse give the client? | Advise the client to come to the clinic right away for further evaluation. |
| What is the best response by the nurse? | This is a very difficult time for you and your family |
| What is the best nursing intervention for the family member's anger? | Encourage the family member to share frustration regarding the loss of the kidney. |
Created by:
Brandi Sizemore