You Selected: • Providing pain-relief measures Correct response: • Limiting fluid intake Explanation: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain. Question 28 A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? You Selected: • Risk for infection Correct response: • Risk for infection Explanation: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self- care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection. Question 29 When a client with an indwelling urinary catheter wants to walk to the hospital lobby to visit with family members, the nurse teaches him how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information? You Selected: • The client keeps the drainage bag below the bladder at all times. Correct response: • The client keeps the drainage bag below the bladder at all times. Explanation: To maintain effective drainage, the client should keep the drainage bag below the bladder; doing so allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn't lay the drainage bag on the floor because the bag could become grossly contaminated. The client shouldn't clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag. Question 30 Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? You Selected: • White blood cell (WBC) count of 20,000/mm3 (0.02 L) Correct response: • White blood cell (WBC) count of 20,000/mm3 (0.02 L) Explanation: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia (evidenced by a blood glucose level of 200 mg/dl) occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower
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- Spring '17
- mrs. Vargovich
- Correct Response, urinary tract infection