The client has a history of Wilms tumor with left radical nephrectomy diagnosed at age five for which he completed treatment nine months ago. A septic episode, while undergoing treatment for his Wilms tumor, resulted in an acute kidney injury. This Injury, along with antibiotic therapy and chemotherapy, has resulted in chronic kidney disease. The client is followed by oncology and nephrology services.
For each nursing action, click to indicate whether the action is indicated or contraindicated for this client's plan of care.
Each row must have only one response option selected.
Continuous pulse oximetry monitoring
Calculation of intake and output
Daily weights
IV 0.9% normal saline continuous infusion at 100 mL/hr
IV potassium sparing diuretic
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Continuous pulse oximetry monitoring is indicated for assessing oxygen saturation and respiratory status, especially in a client with a history of chronic kidney disease and a previous septic episode. It helps monitor the client's respiratory function.
Calculation of intake and output is indicated to assess fluid balance, which is crucial in clients with chronic kidney disease and a history of acute kidney injury. It helps monitor fluid management.
Daily weights are indicated to monitor fluid retention and changes in the client's weight, which can be affected by the client's kidney condition and the administration of intravenous fluids.
IV 0.9% normal saline continuous infusion at 100 mL/hr is indicated to maintain hydration and promote renal function in clients with chronic kidney disease. It helps ensure adequate fluid balance.
IV potassium-sparing diuretics may be contraindicated because they can potentially affect electrolyte balance, and in some cases, they might not be suitable for clients with chronic kidney disease. The use of diuretics should be carefully evaluated and managed by the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","F","G","H"]
Explanation
A. An electrocardiogram with a tall T wave and widened QRS complex may indicate electrolyte imbalances or cardiac issues, which are not indicative of stabilization.
C. Basilar crackles can be a sign of pulmonary or cardiac issues and are not indicative of stabilization.
D. A urine output of 20 mL in the last hour may suggest reduced kidney function or hydration status and is not indicative of stabilization.
E. A respiratory rate of 26 breaths/minute may indicate respiratory distress and is not indicative of stabilization.
The assessment findings that suggest stabilization include:
A blood pressure within the normal range (126/76 mm Hg).
A heart rate within the normal range (72 beats/minute).
Oxygen saturation of 98% on room air, indicating adequate oxygenation.
A normal body temperature (98.9°F or 37.1°C orally).
These vital signs and clinical parameters are within normal ranges, suggesting that the client's condition is stable at this time.
Correct Answer is ["B","F","H"]
Explanation
For this client with a history of Wilms tumor, a radical nephrectomy, chronic kidney disease, and ongoing follow-up by oncology and nephrology services, the nurse should prioritize the following three care needs:
B. Identifying cardiac arrhythmias: Given the history of chronic kidney disease and potential electrolyte imbalances, cardiac arrhythmias are a significant concern that should be assessed and monitored for.
F. Monitoring fluid status: Fluid balance is crucial in clients with chronic kidney disease, and monitoring for fluid overload or dehydration is essential. This is especially important because of the potential need for fluid restrictions.
H. Assessing for worsening respiratory status: Assessing respiratory status is important, as clients with chronic kidney disease may be at risk for respiratory complications, including fluid overload, pulmonary edema, or other issues that can impact their respiratory status.
The other options are not the top priorities based on the client's history and current condition:
A. Collaborating with a dietitian to prepare a low-protein diet is important but may not be the immediate priority.
C. Performing diagnostic testing to determine the cause of a fever is necessary, but it does not take precedence over the immediate concerns of cardiac arrhythmias, fluid status, and respiratory status.
D. Educating the client and family on the importance of fluid restrictions is important, but it is related to monitoring fluid status and may be part of ongoing care.
E. Administering antipyretic medication as needed is relevant for fever management but not a top priority until the cause of the fever is determined.
G. Reassessing vital signs is part of ongoing care but may not be the immediate priority over identifying cardiac arrhythmias and assessing for worsening respiratory status.
I. Investigating acid/base complications is important but may not be the immediate priority when cardiac, fluid, and respiratory status are concerns.
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