Exhibits
For each assessment finding, explain whether the actions taken were effective or ineffective.
DenIes cramps, weakness, ornausea
BP 116/68 mm Hg, HR 75 bpm
Potasslum level 3.6 mEq/L3.6mmol/L)
Verbalizes commitment to dialysisappointments
Client states that she will need to resume her Lisinopril to control blood pressure
Client is eager to add dark green vegetables and potatoes to her diet
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
a) Denies cramps, weakness, or nausea
This finding indicates that the actions taken were effective in relieving the patient's symptoms of fatigue, weakness, muscle cramps, and nausea. These symptoms may have been caused by electrolyte imbalances, dehydration, or infection related to her ESRD and missed dialysis sessions.
b) BP 116/68 mm Hg, HR 75 bpm
This finding indicates that the actions taken were effective in lowering the patient's blood pressure and heart rate. The patient had a history of HTN and CAD and presented with elevated BP and HR in the ED. The orders for EKG, cardiac monitor, chest X-ray, and echocardiogram may have helped to assess and manage her cardiac status. The patient may have also received antihypertensive medications or fluids as part of her treatment.
c) Potassium level 3.6 mEq/L (3.6 mmol/L)
This finding indicates that the actions taken were effective in normalizing the patient's potassium level. The patient had ESRD and missed dialysis sessions, which could have resulted in hyperkalemia or hypokalemia. The orders for basic metabolic panel and blood cultures may have helped to monitor and correct her electrolyte levels. The patient may have also received potassium supplements or binders as part of her treatment.
d) Verbalizes commitment to dialysis appointments
This finding indicates that the actions taken were effective in educating and motivating the patient to adhere to her dialysis schedule. The patient had ESRD and missed dialysis sessions, which could have worsened her condition and increased her risk of complications. The orders for CT scan of abdomen and echocardiogram may have helped to evaluate her renal function and cardiac function. The patient may have also received counseling or support from the health care team as part of her treatment.
e) Client states that she will need to resume her Lisinopril to control blood pressure
This finding indicates that the actions taken were ineffective in teaching the patient about her medication regimen. The patient had a history of HTN and CAD and was prescribed Lisinopril as an antihypertensive medication. However, Lisinopril is contraindicated in patients with ESRD as it can cause hyperkalemia or worsen renal function. The patient should be informed about the potential risks of taking Lisinopril and advised to consult with her nephrologist or primary care provider before resuming it.
f) Client is eager to add dark green vegetables and potatoes to her diet
This finding indicates that the actions taken were ineffective in educating the patient about her dietary restrictions. The patient had ESRD and required hemodialysis three times a week. She should follow a renal diet that limits the intake of potassium, phosphorus, sodium, and fluid. Dark green vegetables and potatoes are high in potassium and phosphorus and should be avoided or consumed in moderation by patients with ESRD. The patient should be provided with a list of foods that are suitable for her condition and referred to a dietitian for further guidance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Sodium polystyrene sulfonate is a medication that binds to excess potassium in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can cause cardiac arrhythmias and muscle weakness, and it is a common complication of AKI. Therefore, this medication should be administered first to lower the potassium level and prevent life-threatening complications.
Choice B reason: Sevelamer is a medication that binds to phosphorus in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperphosphatemia, which is a high level of phosphorus in the blood. Hyperphosphatemia can cause bone loss and soft tissue calcification, and it is a common complication of chronic kidney disease (CKD). However, it is not an urgent issue in AKI, and it does not affect the potassium level.
Choice C reason: Calcium acetate is a medication that also binds to phosphorus in the gastrointestinal tract and removes it from the body through feces. It has the same effect and indication as sevelamer, but it also provides calcium supplementation. However, it is not an urgent issue in AKI, and it does not affect the potassium level.
Choice D reason: Epoetin alfa, recombinant is a medication that stimulates the production of red blood cells in the bone marrow. It is used to treat anemia, which is a low level of hemoglobin or red blood cells in the blood. Anemia can cause fatigue, weakness, and shortness of breath, and it is a common complication of CKD and AKI. However, it is not an urgent issue in AKI, and it does not affect the potassium level.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because teaching the client to wear a mask, hand wash, and social distance is not the most important action for the nurse to take. These are preventive measures that should be followed by everyone, regardless of their COVID-19 status.
Choice B reason: This is correct because isolating the client from other clients, family, and healthcare workers not wearing proper PPE is the most important action for the nurse to take. This is to prevent transmission of COVID-19 to others who may be at risk of severe complications or death.
Choice C reason: This is incorrect because reporting the COVID-19 result to the local health department according to CDC guidelines is not the most important action for the nurse to take. This is a legal and ethical obligation that should be done after confirming the diagnosis, but it does not have an immediate impact on the client's health or safety.
Choice D reason: This is incorrect because explaining to the client to inform others that they may have been potentially exposed in the last 14 days is not the most important action for the nurse to take. This is a moral and social responsibility that should be done as soon as possible, but it does not address the urgent need of isolating the client from potential sources of infection.
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