The nurse is caring for a client with end-stage renal disease (ESRD) who is anuric and receives hemodialysis three times a week. During a routine assessment, the patient expresses frustration about strict fluid restrictions and states, “I don’t even make urine anymore, so why does it matter how much I drink?” Which of the following is the most appropriate response by the nurse?
Because your kidneys no longer produce urine, fluid can build up quickly and lead to complications like high blood pressure or difficulty breathing
You should actually drink more fluids to stay hydrated since you’re not urinating
As long as you’re attending all your dialysis sessions, your fluid intake doesn’t need to be restricted
It’s not the fluids that are harmful, it’s the foods that are high in potassium and phosphorus
The Correct Answer is A
Choice A reason: In ESRD, anuria means no urine output, so excess fluid accumulates in the body, increasing intravascular volume. This can cause hypertension, pulmonary edema, and respiratory distress. Educating the client about these risks emphasizes the importance of fluid restrictions to prevent life-threatening complications between dialysis sessions, addressing their frustration accurately.
Choice B reason: Advising increased fluid intake is incorrect for anuric ESRD patients, as their kidneys cannot excrete fluid. This would exacerbate fluid overload, leading to hypertension, heart failure, or pulmonary edema. Hydration is managed through dialysis, not increased oral intake, which could overwhelm the body’s limited fluid-handling capacity.
Choice C reason: Stating that fluid intake is unrestricted with dialysis is incorrect. Even with regular dialysis, excessive fluid intake between sessions can lead to overload, causing hypertension or pulmonary edema. Dialysis removes a limited amount of fluid per session, requiring strict restrictions to maintain safe fluid balance and prevent complications.
Choice D reason: While potassium and phosphorus restrictions are critical in ESRD to prevent hyperkalemia and hyperphosphatemia, the client’s question focuses on fluid restrictions. This response does not address fluid overload risks like hypertension or pulmonary edema, which are direct consequences of excessive fluid intake in anuric patients, making it irrelevant to the query.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.5"]
Explanation
Step 1 is identify the total dose ordered
10 mg
Step 2 is identify the concentration available
4 mg per mL
Step 3 is divide the ordered dose by the concentration per mL
(10 ÷ 4) = 2.5
Result = 2.5 mL
Correct Answer is B
Explanation
Choice A reason: Violating a nurse’s boundaries, such as inappropriate behavior, does not legally mandate breaching confidentiality. Ethical responses involve setting boundaries or reporting within the care team, but confidentiality is protected unless harm to others is threatened, making this situation insufficient for a legal breach.
Choice B reason: Nurses are legally obligated to breach confidentiality when a client makes credible threats to harm an identifiable third party (Tarasoff duty). This protects potential victims by ensuring warnings or interventions occur, balancing patient confidentiality with public safety, as harm prevention takes precedence in mental health law.
Choice C reason: Client aggression does not automatically warrant breaching confidentiality unless it involves specific threats to identifiable individuals. Aggression is managed within the care setting, and confidentiality is maintained unless legal criteria, like imminent harm to others, are met, making this option incorrect.
Choice D reason: Disagreement with the nurse does not justify breaching confidentiality. Ethical care respects client autonomy, and confidentiality is protected unless legal exceptions, like threats or court orders, apply. Disagreement is managed through therapeutic communication, not by disclosing private information, making this an invalid reason for breach.
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