ANSWERS RATIONALE 41-80

41.

1. Hyperkalemia places the client at risk

for serious cardiac arrhythmias and cardiac arrest.
Therefore, the nurse should carefully monitor the
client for cardiac arrhythmias and be prepared to
treat cardiac arrest when caring for a client with
hyperkalemia. Increased potassium levels do not
result in pulmonary edema, circulatory collapse, or
hemorrhage.
CN: Pharmacological and parenteral
therapies; CL: Analyze

42.

4. High-carbohydrate foods meet the bodys

caloric needs during acute renal failure. Protein
is limited because its breakdown may result in
accumulation of toxic waste products. The main
goal of nutritional therapy in acute renal failure
is to decrease protein catabolism. Protein catabolism
causes increased levels of urea, phosphate,
and potassium. Carbohydrates provide energy and
decrease the need for protein breakdown. They do
not have a diuretic effect. Some specifi c carbohydrates
infl uence urine pH, but this is not the reason
for encouraging a high-carbohydrate, low-protein
diet. There is no need to reduce demands on the
liver through dietary manipulation in acute renal
failure.
CN: Basic care and comfort; CL: Apply

43.

1. Gelatin desserts contain little or no potassium

and can be served to a client on a potassiumrestricted
diet. Foods high in potassium include
bran and whole grains; most dried, raw, and frozen
fruits and vegetables; most milk and milk products;
chocolate, nuts, raisins, coconut, and strong brewed
coffee.
CN: Basic care and comfort; CL: Apply

44.

1. Pulmonary edema can develop during

the oliguric phase of acute renal failure because of
decreased urine output and fl uid retention. Metabolic
acidosis develops because the kidneys cannot
excrete hydrogen ions, and bicarbonate is used to
buffer the hydrogen. Hypertension may develop as a
result of fl uid retention. Hyperkalemia develops as
the kidneys lose the ability to excrete potassium.
CN: Physiological adaptation;
CL: Analyze

45.

1. The unaffected arm should be used for

blood pressure measurement. The external cannula
must be handled carefully and protected from
damage and disruption. In addition, a tourniquet
or clamps should be kept at the bedside because
dislodgment of the cannula would cause arterial
hemorrhage. The arm with the cannula is not used

for blood pressure measurement, I.V. therapy, or

venipuncture. Patency is assessed by auscultating
for bruits every shift. Heparin is not injected into
the cannula to maintain patency. Because it is part
of the general circulation, the cannula cannot be
heparinized.
CN: Reduction of risk potential;
CL:Synthesize

46.

1. Common symptoms of disequilibrium syndrome

include headache, nausea and vomiting, confusion,
and even seizures. Disequilibrium syndrome
typically occurs near the end or after the completion
of hemodialysis treatment. It is the result of rapid changes in solute composition and
osmolality of the
extracellular fl uid. These symptoms are not related
to cardiac function, air embolism, or peritonitis.
CN: Reduction of risk potential;
CL: Analyze

47.

2. If disequilibrium syndrome occurs during

dialysis, the most appropriate intervention is to
slow the rate of dialysis. The syndrome is believed
to result from too-rapid removal of urea and excess
electrolytes from the blood; this causes transient
cerebral edema, which produces the symptoms.
Administration of oxygen and position changes do
not affect the symptoms. It would not be appropriate
to reassure the client that the symptoms are normal.
CN: Reduction of risk potential;
CL: Synthesize

48.

1. Regional anticoagulation can be achieved

by infusing heparin in the dialyzer and protamine
sulfate, its antagonist, in the client. Warfarin sodium
(Coumadin) is not used in dialysis treatment. There
is some risk of bleeding; however, clotting time is
monitored carefully. The clients clotting time will
not be seriously affected, although some rebound
effect may occur.
CN: Pharmacological and parenteral
therapies; CL: Apply

49.

3. Dialysis has no effect on anemia. Because

some red blood cells are injured during the procedure,
dialysis aggravates a low hemoglobin concentration.
Dialysis will clear metabolic waste products
from the body and correct electrolyte imbalances.
CN: Reduction of risk potential;
CL: Apply

50.

4. Signs and symptoms of an external access

shunt infection include redness, tenderness, swelling,
and drainage from around the shunt site. The
absence of a bruit indicates closing of the shunt.
Sluggish capillary refi ll time and coolness of the
extremity indicate decreased blood fl ow to the
extremity.

CN: Reduction of risk potential;

CL: Analyze

51.

1. The kidneys have a remarkable ability to

recover from serious insult. Recovery may take 3 to
12 months. The client should be taught how to recognize
the signs and symptoms of decreasing renal
function and to notify the physician if such problems
occur. In a client who is recovering from acute
renal failure, there is no need for renal transplantation
or permanent hemodialysis. Chronic renal
failure develops before end-stage renal failure.
CN: Physiological adaptation; CL: Apply

The Client with Urinary

Tract Infection

52.

4. The sensation of thirst diminishes in those

greater than 60 years of age; hence, fl uid intake is
decreased and dissolved particles in the extracellular
fl uid compartment become more concentrated.
There is no change in liver function in older adults,
nor is there a reduction of ADH and aldosterone as a
normal part of aging.
CN: Physiological adaptation;
CL: Apply

53.

3. Antibiotics have the maximum effect when

a blood level of the medication is maintained. However,
because nitrofurantoin (Macrodantin) is readily
absorbed from the gastrointestinal tract and is
primarily excreted in urine, toxicity may develop by
doubling the dose. The client should not skip a dose
if she realizes that she has missed one. Additional
fl uids, especially water, should be encouraged, but
not forced to promote elimination of the antibiotic
from the body. Adequate fl uid intake aids in the
prevention of urinary tract infections, in addition to
an acidic urine.
CN: Pharmacological and parenteral
therapies; CL: Synthesize

54.

1. The clients urine specifi c gravity is elevated.

Specifi c gravity is a refl ection of the concentrating
ability of the kidneys. This level indicates
that the urine is concentrated. By increasing fl uid
intake, the urine will become more dilute. Antihypertensives
do not make urine more concentrated
unless there is a diuretic component within them.
The nurse should not hold a dose of antihypertensive
medication. Sodium tends to pull water with
it; by restricting sodium, less water, not more, will
be present. Bananas do not aid in the dilution of
urine.
CN: Reduction of risk potential;
CL: Synthesize

55.

1. All urine for creatinine clearance determination

must be saved in a container with no

preservatives and refrigerated or kept on ice. The

fi rst urine voided at the beginning of the collection
is discarded, not the last. A self-report of weight
may not be accurate. It is not necessary to have an
indwelling urinary catheter inserted for urine collection.
CN: Reduction of risk potential;
CL: Apply

56.

141 mg
1 22
1
kg lb
1kg:2.2lb= kg:207lb
2.2lb kg=1kg 207lb
kg=
kg 207

.
X
X
X
lb
lb
kg
1.5mg 94.1=141.15=141mg.
94 1
1
22
94 1
.
.
X .

CN: Pharmacological and parenteral

therapies; CL: Apply

57.

2. The classic symptoms of cystitis are severe

burning on urination, urgency, and frequent urination.
Systemic symptoms, such as fever and nausea
and vomiting, are more likely to accompany pyelonephritis
than cystitis. Hematuria may occur, but it
is not as common as frequency and burning.
CN: Physiological adaptation;
CL: Analyze

58.

4. Although various conditions may result

in cystitis, the most common cause is an ascending
infection from the urethra. Strictures and urine
retention can lead to infections, but these are not the
most common cause. Systemic infections are rarely
causes of cystitis.
CN: Physiological adaptation; CL: Apply

59.

4. As newlyweds, the client and her husband

need to develop a strong communication base. The

nurse can facilitate communication by preparing and

supporting the client. Given the situation, an interdisciplinary
conference is inappropriate and would
not promote intimacy for the client and her husband.
Insisting that the client talk with her husband is not
addressing her fears. Being present allows the nurse
to facilitate the discussion of a diffi cult topic. Having
the nurse speak fi rst with the husband alone shifts
responsibility away from the couple.
CN: Psychosocial adaptation;
CL: Synthesize

60.

2. Hot tub baths promote relaxation and help

relieve urgency, discomfort, and spasm. Applying
heat to the perineum is more helpful than cold
because heat reduces infl ammation. Although
liberal fl uid intake should be encouraged, caffeinated
beverages, such as tea, coffee, and cola, can
be irritating to the bladder and should be avoided.
Voiding at least every 2 to 3 hours should be encouraged
because it reduces urinary stasis.
CN: Basic care and comfort; CL: Evaluate

61.

3. Phenazopyridine hydrochloride (Pyridium)

is a urinary analgesic that works directly on
the bladder mucosa to relieve the distressing symptoms
of dysuria. Phenazopyridine does not have a
bacteriostatic effect. It does not potentiate antibiotics
or prevent crystallization.
CN: Pharmacological and parenteral
therapies; CL: Apply

62.

1. The client should be told that

phenazopyridine hydrochloride (Pyridium) turns
the urine a bright orange-red, which may stain
underwear. It can be frightening for a client to see
orange-red urine without having been forewarned.
Other common adverse effects associated with
phenazopyridine include headaches, gastrointestinal
disturbances, and rash. Phenazopyridine does
not cause incontinence, constipation, or drowsiness.
CN: Pharmacological and parenteral
therapies; CL: Apply

63.

2, 3. Clients who are taking nitrofurantoin

(Macrodantin) should be instructed to take the
medication with meals and to increase their fl uid
intake to minimize gastrointestinal distress. The
urine may become brown in color. Although this
change is harmless, clients need to be prepared for
this color change. The client should be instructed to
take the full prescription and not to stop taking the
drug because symptoms have subsided. The medication
should not be taken with antacids as this may
interfere with the drugs absorption.
CN: Pharmacological and parenteral
therapies; CL: Synthesize

64.

15 mL
The following formula is used to calculate the correct
dosage:
25 mg/5 mL = 75 mg/X mL
X = 15 mL.
CN: Pharmacological and parenteral
therapies; CL: Apply

65.

1. Stasis of urine in the bladder is one of the

chief causes of bladder infection, and a client who
voids infrequently is at greater risk for reinfection.
A tub bath does not promote urinary tract infections
as long as the client avoids harsh soaps and bubble
baths. Scrupulous hygiene and liberal fl uid intake
(unless contraindicated) are excellent preventive
measures, but the client also should be taught to
void every 2 to 3 hours during the day.
CN: Reduction of risk potential;
CL: Analyze

66.

1. A woman can adopt several healthpromotion

measures to prevent the recurrence of cystitis, including avoiding too-tight pants, noncotton
underpants, and irritating substances, such as
bubble baths and vaginal soaps and sprays. Increasing
citrus juice intake can be a bladder irritant.
Regular douching is not recommended; it can alter
the pH of the vagina, increasing the risk of infection.
CN: Health promotion and maintenance;
CL: Synthesize

67.

4. Instructions should be as specifi c as possible,

and the nurse should avoid general statements
such as a lot. A specifi c goal is most useful. A
mix of fl uids will increase the likelihood of client
compliance. It may not be suffi cient to tell the client
to drink twice as much as or 1 quart more than she
usually drinks if her intake was inadequate to begin
with.
CN: Basic care and comfort; CL: Apply

The Client with Pyelonephritis

68.

1. Pyelonephritis usually begins with colonization

and infection of the lower urinary tract via
the ascending urethral route, and the client should
have an adequate intake of fl uids to promote the
fl using action of urination. Bubble baths and limiting
fl uid intake increase the risk of developing a
urinary tract infection. Antibiotics should be used
on a short-term basis because the risk of antibiotic
resistance may lead to breakthrough infections with
increasingly virulent pathogens.
CN: Health promotion and maintenance;
CL: Synthesize

69.

2. Common symptoms of pyelonephritis

include CVA tenderness, burning on urination, urinary
urgency or frequency, chills, fever, and fatigue.
Ascites, polyuria, and nausea and vomiting are not

indicative of pyelonephritis.
CN: Physiological adaptation;
CL: Analyze

70.

4. A client with a history of diabetes mellitus,

urinary tract infections, or renal calculi is at
increased risk for pyelonephritis. Others at high risk
include pregnant women and people with structural
alterations of the urinary tract. A history of hypertension
may put the client at risk for kidney damage,
but not kidney infection. Intake of large quantities of
cranberry juice and a fl uid intake of 2,000 mL/day
are not risk factors for pyelonephritis.
CN: Reduction of risk potential;
CL: Analyze

71.

5, 6. Serum BUN and creatinine are the

tests most commonly used to assess renal function,
with creatinine being the most reliable indicator.
Nonrenal factors may affect BUN levels as well as
serum sodium and potassium levels. Arterial blood
gases and hemoglobin are not used to assess renal
status. Urinalysis is a general screening test.
CN: Physiological adaptation;
CL: Analyze

72.

3. Antibiotics are usually prescribed for a

2- to 4-week period. A urine culture is needed to
evaluate the effectiveness of antibiotic therapy.
Urine must be examined microscopically to adequately
determine the presence of bacteria; looking
at the color of the urine or checking the odor is not
suffi cient. Symptoms usually disappear 48 to 72
hours after antibiotic therapy is started, but antibiotics
may need to continue for up to 4 weeks.
CN: Pharmacological and parenteral
therapies; CL: Evaluate

73.

2. Chronic pyelonephritis is most commonly

the result of recurrent urinary tract infections.
Chronic pyelonephritis can lead to chronic renal
failure. Single cases of acute pyelonephritis rarely
cause chronic pyelonephritis. Acute renal failure is
not a cause of chronic pyelonephritis. Glomerulonephritis
is an immunologic disorder, not an infectious
disorder.
CN: Physiological adaptation; CL: Apply

The Client with Chronic Renal Failure

74.

1. Crackles in the lungs, weight gain, and elevated

blood pressure are indicators of excess fl uid
volume, a common complication in chronic renal
failure. The clients fl uid status should be monitored
carefully for imbalances on an ongoing basis.
Although the client has ineffective breathing, the
primary cause is related to the renal failure. There
are no data to suggest ineffective tissue perfusion or
lack of knowledge.

CN: Physiological adaptation;

CL: Analyze

75.

3. A disadvantage of peritoneal dialysis in

long-term management of chronic renal failure is
that it requires large blocks of time. The risk of
hemorrhage or hepatitis is not high with peritoneal
dialysis. Peritoneal dialysis is effective in maintaining
a clients fl uid and electrolyte balance.
CN: Reduction of risk potential;
CL: Apply

76.

2, 4, 5. To manage nausea, the nurse can

advise the client to drink limited amounts of fl uid
only when thirsty, eat food before drinking fl uids to
alleviate dry mouth, encourage strict follow-up for blood work, dialysis, and health care
provider visits.
Smaller, more frequent meals may help to reduce
nausea and facilitate medication taking. The client
should be as active as possible to avoid immobilization
because it increases bone demineralization. The
client should also maintain the dialysis schedule
because the dialysis will remove wastes that can
contribute to nausea.
CN: Physiological adaptation;
CL: Synthesize

77.

1. The main reason for warming the peritoneal

dialysis solution is that the warm solution
helps dilate peritoneal vessels, which increases urea
clearance. Warmed dialyzing solution also contributes
to client comfort by preventing chilly sensations,
but this is a secondary reason for warming the
solution. The warmed solution does not force potassium
into the cells or promote abdominal muscle
relaxation.
CN: Reduction of risk potential;
CL: Apply

78.

2. During dwell time, the dialysis solution

is allowed to remain in the peritoneal cavity for the
time ordered by the physician (usually 20 to 45 minutes).
During this time, the nurse should monitor
the clients respiratory status because the pressure
of the dialysis solution on the diaphragm can create
respiratory distress. The dialysis solution would not
cause urticaria or affect circulation to the fi ngers.
The clients laboratory values are obtained before
beginning treatment and are monitored every 4 to
8 hours during the treatment, not just during the
dwell time.
CN: Reduction of risk potential;
CL: Analyze

79.

2. Because the client has a permanent catheter

in place, blood-tinged drainage should not occur.
Persistent blood-tinged drainage could indicate
damage to the abdominal vessels, and the physician

should be notifi ed. The bleeding is originating

in the peritoneal cavity, not the kidneys. Too-rapid
infusion of the dialysate can cause pain, not bloodtinged
drainage.
CN: Reduction of risk potential;
CL: Analyze

80.

2. Fluid return with peritoneal dialysis is

accomplished by gravity fl ow. Actions that enhance
gravity fl ow include turning the client from side to
side, raising the head of the bed, and gently massaging
the abdomen. The client is usually confi ned to
a recumbent position during the dialysis. The nurse
should not attempt to reposition the catheter.
CN: Reduction of risk potential;
CL: Synthesize