Points Awarded Points Missed Percentage Etiology

30.00 5.00 85.7%

End-stage renal disease (ESRD) is the last stage in the progressive clinical syndrome called chronic kidney disease (CKD).

1. What is the best description of CKD? A) There are frequent exacerbations since half of all nephrons are damaged. INCORRECT Half of all nephrons are often damaged in acute renal failure. In CKD, about 90% of nephrons are typically involved. B) Condition has a rapid onset with frequent remissions. INCORRECT Acute renal failure has a rapid onset, but chronic kidney disease has a gradual onset, occurring over months or years. Neither form of renal failure has frequent periods of remission. C) It is a fatal disorder unless renal replacement therapy is received. CORRECT CKD is fatal unless some form of renal replacement therapy (dialysis or organ transplant) is done, whereas acute renal failure has a good prognosis for the return of kidney function if appropriate supportive care is provided during the acute period. D) Symptoms are reversible with life long medication. INCORRECT Chronic kidney disease is progressive, irreversible kidney injury. Acute renal failure may be reversible with adequate supportive care during the acute episode.

CKD is a disorder with a complex etiology involving many interrelated factors. Diabetes mellitus is a known risk factor for renal failure.

2. What additional information in Louellen's history may be related to the onset of ESRD?

A) Hysterectomy at age 35. INCORRECT This is not a risk factor for CKD. B) Hypertension. CORRECT Hypertension is one of the primary causes of CKD. The vast majority of clients with CKD have hypertension, which may be either the cause or the result of CKD. C) Female gender. INCORRECT CKD does not seem to be more common in either gender. D) Use of diuretics. INCORRECT Use of diuretics is not a cause of CKD, but obtaining a medication history is important since many medications are nephrotoxic.

Diagnostic Evaluation

The following diagnostic tests were performed:

Hemoglobin. Serum creatinine and BUN. Serum calcium. Arterial blood gases. Serum potassium. Serum phosphorus. Urinary creatinine clearance.

3. Which lab value is likely to be decreased in a client with chronic kidney disease? A) Serum creatinine and BUN. INCORRECT Serum creatinine and BUN are tests which evaluate the removal of nitrogenous wastes by the kidney. Both are increased in chronic kidney disease, although BUN levels are directly impacted by protein intake, hydration status, and other factors. B) Serum calcium. CORRECT

Serum calcium is decreased in CKD in response to an increase in serum phosphorous. C) Serum phosphorous. INCORRECT Serum phosphorous is increased as less phosphorous is excreted by the kidney. D) Serum potassium. INCORRECT Serum potassium levels are increased in CKD as the kidney loses the ability to remove potassium from the body. Clients with CKD should be assessed carefully for symptoms of hyperkalemia.

The nurse notes that Louellen's Hemoglobin level is 7.8.

4. What is the underlying pathology causing this abnormal lab value? A) Fewer red blood cells are being formed. CORRECT Hemoglobin is decreased as the kidneys become less able to produce erythropoietin necessary for the formation of red blood cells. B) Renal waste products destroy red blood cells. INCORRECT This does not occur. C) Hematuria results in blood loss. INCORRECT CKD does not result in hematuria. D) Dehydration causes dilutional anemia. INCORRECT If dehydration occurred, it would be more likely to result in a high hemoglobin level rather than a low level.

Louellen's arterial blood gas (ABG) results are:

pH 7.35. PO2 96.00 mmHg.

 PCO2 30.00 mmHg. HCO3 18.00 mEq/L.

5. What is the correct interpretation of these ABGs? A) Metabolic acidosis (compensated). CORRECT As excessive bicarbonate is excreted, the HCO3 level decreases, causing metabolic acidosis (decreased pH). Compensation occurs when an increased rate and depth of respirations reduce the CO2 levels, returning the pH to low normal. B) Respiratory alkalosis (compensated). INCORRECT Alkalosis would be indicated by an increased pH rather than decreased pH. C) Respiratory acidosis (compensated). INCORRECT This is a compensated acidosis, but if it were respiratory in nature, the CO 2 would be elevated rather than decreased. D) Metabolic alkalosis (compensated). INCORRECT Alkalosis would be indicated by an increased pH rather than decreased pH.

Clinical Manifestations

Louellen's diagnostic tests confirm the medical diagnosis of end-stage renal disease. In addition to Louellen's complaints of fatigue, anorexia, dyspnea, and nocturia, the nurse's assessment findings include: +1 pedal edema, basilar crackles in both lungs, and clear, pale urine. Louellen's VS are: T 98.8 F, P 86, R 28, and BP 178/92.

6. Which additional assessment finding is consistent with ESRD? A) Yellow-gray pallor. CORRECT

The client with ESRD often exhibits a yellow-gray pallor as the result of anemia and uremia. In addition, the client with ESRD may exhibit other skin manifestations such as bruising and uremic frost (a very late manifestation). B) Clay-colored stool. INCORRECT This is not a manifestation seen in ESRD. C) Fingernail clubbing. INCORRECT This finding is typical in clients with chronic lung disorders, but not in ESRD. D) Stridor. INCORRECT Stridor is a crowing respiratory noise due to bronchoconstriction. It is not an expected finding in ESRD.

The nurse notes that Louellen's blood pressure is elevated.

7. Which explanation best describes the pathology resulting in her hypertension? A) Activation of the renin-angiotensin cycle and excretion of aldosterone causes hypertension. CORRECT The renin-angiotensin cycle causes vasoconstriction of the periphery which increases the blood pressure. In addition, the excretion of aldosterone causes the retention of sodium and water, further increasing the fluid volume which increases the blood pressure. B) Irritation of the pericardial lining of the heart due to uremic toxins increases blood pressure. INCORRECT This explains the cause of pericarditis. C) An increase in the excretion of sodium and water from the kidneys causes hypertension. INCORRECT Hypertension would be caused by an increase in the retention of sodium and water rather than an increase in the excretion of sodium and water. D) The increase of uremic waste products in the blood stream increases the blood pressure. INCORRECT

This is the probable cause for gastrointestinal manifestations such as anorexia, nausea, and vomiting.

Pharmacologic Management

Louellen receives prescriptions for the following medications:

Calcium acetate (Phoslo) 2 gelcaps (667 mg each) PO with each meal. Ferrous sulfate (Feosol) 1 tablet PO (65 mg) daily. Epoetin alfa (Epogen) 3900 units subcutaneously 3 times per week (dosed at 75 U/kg

three times a week). Glipizide (Glucotrol) 10 mg PO daily - take 30 minutes before breakfast. Furosemide (Lasix) 40 mg PO twice daily. Captopril (Capoten) 25 mg PO twice daily. Potassium chloride (Kay Ciel) elixir 40 mEq PO three times daily.

8. Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate (Phoslo) has been achieved? A) Serum phosphorous of 4.0 mg/dl. CORRECT Calcium acetate (Phoslo) acts as a phosphate binder, reducing the high serum phosphorous levels commonly found in the client with CKD. B) Serum hematocrit of 32%. INCORRECT Hematocrit is not affected by the use of Phoslo. C) Serum hemoglobin of 12 g/dl. INCORRECT Hemoglobin is not affected by the use of Phoslo. D) Serum glucose of 90 mg/dl. INCORRECT This normal glucose level is managed with the client's glipizide (Glucotrol).

9. Which assessment should the nurse perform to determine if the desired outcome of the captopril (Capoten) has been achieved?

A) Fingerstick glucose. INCORRECT This would be an appropriate assessment measure for a hypoglycemic agent such as glipizide (Glucotrol), but not for captopril. B) Intake and output. INCORRECT This would be an appropriate assessment measure for a diuretic such as fuorsemide (Lasix), but not for captopril. C) Apical pulse. INCORRECT This does not provide data as to the desired outcome of the captopril. D) Blood pressure. CORRECT Captopril (Capoten) is an ACE inhibitor used as an antihypertensive agent.

10. Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa (Epogen) has been achieved? A) Normo-active bowel sounds. INCORRECT This is not an indicator for the desired outcome of Epogen. B) Ate 100% of diet. INCORRECT This is not the BEST indicator that the desired outcome of Epoetin has been achieved, although an improvement in dietary intake may be a secondary benefit of a reduction in fatigue. C) No further edema. INCORRECT This assessment finding is an indicator used to assess the effectiveness of a diuretic such as fuorsemide (Lasix), but not Epogen. D) Conjunctival sac returns to a reddish-pink color. CORRECT This assessment finding reflects an improvement in the client's anemia. Epogen stimulates the production of RBCs, resulting in an increase in hematocrit. It is used to treat the anemia common in clients with CKD.

Nursing Diagnoses and Interventions

Louellen is admitted to an acute care facility for management of her ESRD. The nurse's plan of care includes the following nursing diagnoses:

Fluid volume excess. Altered nutrition: less than body requirements. Decreased cardiac output. Fatigue. Constipation. Risk for injury.

11. Based on these diagnoses, which nursing intervention should be included in Louellen's plan of care? A) Monitor and record daily weights. CORRECT Daily weights are an essential assessment of the degree of fluid volume excess. Remember, 1 kg of weight gain equals about 1 liter of retained fluid. The cornerstones of conservative management of CKD are fluid restriction, diet therapy, and drug therapy. B) Encourage oral fluid intake. INCORRECT Fluid restrictions will be instituted. C) Avoid any subcutaneous and intramuscular injections. INCORRECT Although the client with CKD is likely to bruise easily due to a reduction in platelets, avoidance of injections is not necessary. D) Offer frequent high-protein snacks. INCORRECT Protein is restricted to reduce the accumulation of waste products associated with protein metabolism, which causes the manifestations of uremia.

Louellen asks the nurse if she can eat eggs.

12.

The nurse's response is based on what understanding? A) Eggs are considered an incomplete protein source. INCORRECT Eggs are considered a complete protein. B) Eggs are a source of high biologic value protein. CORRECT Since protein intake is restricted, the protein allowed should be of high biologic value, such as eggs. C) Eggs are a high-fat food and should be avoided. INCORRECT Eggs are only high in fat if cooked in fat, such as when fried in oil or bacon grease. D) Eggs contain too much protein and are not allowed. INCORRECT Eggs are a good source of protein.

Louellen has a urinary output of 120 ml for the previous 24 hours. She is on fluid restriction.

13. How much fluid will Louellen be allowed to drink during the next 24 hours? A) 1,000 ml of fluid. INCORRECT This is not the correct amount for Louellen. B) 450 ml of fluid. INCORRECT This is not the correct amount for Louellen. C) 20 ml of fluid. INCORRECT This is not the correct amount for Louellen. D) 720 ml of fluid. CORRECT Usually the fluid allowance is 500 to 600 ml more than the previous day's 24-hour urine output.

Ethical/Legal Considerations: Medication Administration

The nurse notes that the prescribed medications include potassium chloride (Kay Ciel) elixir 40 mEq PO 3 times a day. Prior to administering the medication, the nurse monitors Louellen's serum potassium level, which is 6.5 mmol/L.

14. What is the best nursing intervention? A) Ask the pharmacist to supply a tablet rather than an elixir since Louellen is on fluid restriction. INCORRECT Because this requires a change in prescription, the health care provider must be contacted regarding this change. Since the administration of this prescription would be unsafe for the client in any form, there is another intervention that should be implemented. B) Calculate the milliliters of medication needed and record the amount on the fluid intake record. INCORRECT If the potassium level was within normal limits and the medication was to be given, this would be an appropriate intervention. However, since the potassium level is high, this is not the correct intervention. C) Hold the dose of Kay Ciel and contact the health care provider to report the serum potassium level. CORRECT The serum potassium level is elevated, and administering additional potassium in any form is potentially dangerous to the client. D) Administer the dose of Kay Ciel and document the serum potassium level in the medical record. INCORRECT This is not an appropriate intervention considering the client's elevated serum potassium level.

The nurse reports the serum potassium level to the health care provider's office nurse, who calls back and tells the nurse that the health care provider wants the dose of Kay Ciel reduced by half and changed to an oral tablet, rather than an elixir.

15.

What intervention should the nurse implement? A) Administer the prescribed tablet. INCORRECT This is an unsafe intervention since the client's serum potassium is elevated. B) Request a faxed copy of the prescription. INCORRECT Requesting a written copy of a prescription is always desirable, but in this case will only confirm an unsafe prescription. C) Obtain the name of the office nurse. INCORRECT This is an appropriate action, but it is not the most important action at this time. D) Ask to speak directly with the health care provider. CORRECT The medication prescription is unsafe and requires direct communication with the prescribing health care provider.

The nurse consults with the health care provider, who becomes angry, and tells the nurse that health care provider's orders should never be questioned.

16. Which statement should serve as the basis for the nurse's reply? A) Only the prescribing health care provider is legally liable for the administration of a prescribed, but unsafe, medication. INCORRECT This is an inaccurate statement. Liability extends beyond the health care provider. B) The RN job description in most hospital policy manuals clearly states that adhering to the health care provider's prescriptions is required. INCORRECT The nurse must use sound professional judgment to determine if a prescribed medication or treatment is safe, and should collaborate with the prescribing health care provider. In addition, the nurse must be careful to act within the limitations of the state nurse practice act, and may not administer a medication or medical treatment without a prescription. C) State nurse practice acts indicate that the professional nurse should only administer legally prescribed medications. INCORRECT

The nurse practice act in each state does establish the legal regulation of the practice of nursing. However, the issue in question is not the legality of the prescription, but rather, the safety of the prescription. D) The professional nurse can be held accountable for the administration of any unsafe medication. CORRECT The professional nurse can be held legally liable for the administration of an unsafe medication.

Hemodialysis

Louellen's urinary output continues to diminish, and her lab values indicate worsening kidney function. The health care provider and nurse discuss types of dialysis with Louellen. She must consider the benefits and risks of both peritoneal dialysis and hemodialysis.

17. Which factor is related to the use of hemodialysis? A) Treatments require more time. INCORRECT Peritoneal dialysis typically requires a longer period of time for the exchange of fluid than does hemodialysis. B) High risk for air embolus. CORRECT The client with hemodialysis is at high risk for air embolus since vascular access is required. C) More easily performed at home. INCORRECT Peritoneal dialysis is more easily performed at home because hemodialysis requires more complex machinery and a treated water supply, and it is more likely to cause hemodynamic instability. D) High risk of abdominal infection. INCORRECT Peritoneal dialysis places the client at high risk for peritonitis since the catheter and fluid enter the peritoneal cavity.

18. Louellen is at increased risk for the development of which problem while receiving hemodialysis? A) Ascites. INCORRECT Ascites is not a potential complication of hemodialysis. B) Hepatitis B and C. CORRECT Clients on hemodialysis are at greater risk for contracting hepatitis B and C than clients on peritoneal dialysis because of the equipment used in hemodialysis. Hepatitis B vaccine is encouraged for clients with chronic kidney disease. C) Hypertension. INCORRECT The client is at risk for developing hypotension during treatment due to the fluid being removed. Nausea, vomiting, diaphoresis, tachycardia, and dizziness are common signs of hypotension. D) Blood clot formation. INCORRECT The client must be heparinized during hemodialysis. Therefore, bleeding is a more likely potential complication than thrombosis.

Vascular Access Devices

Louellen decides that hemodialysis is the best choice for her. An arteriovenous (AV) graft is surgically placed in her right forearm, and a dual-lumen hemodialysis catheter is placed for temporary use until her permanent AV graft site heals.

19. What is the best description of an AV graft? A) Synthetic tubing tunneled beneath the skin connecting an artery and a vein. CORRECT These grafts can be placed in the arm or inner thigh and can be used within 1 to 2 weeks of surgery. B) Internal surgical anastomosis between an artery and a vein. INCORRECT This describes an AV fistula, typically located in the forearm. AV fistulas require prolonged healing (2 to 4 months) before use.

C) External loop of synthetic tubing connecting an artery and a vein. INCORRECT This describes an AV shunt. Shunts can be used immediately after insertion, but since the advent of central line catheters, shunts are no longer commonly used. D) Central line tunneled catheter with a barrier cuff. INCORRECT This describes a soft flexible catheter that is tunneled under the skin and placed in the superior vena cava. The cuff keeps the catheter in place and serves as a barrier to infection.

While assessing Louellen's AV graft site, the nurse palpates a buzzing sensation directly over the graft.

20. Which documentation should the nurse enter into the nurses' notes? A) Thrill present and palpated. CORRECT This buzzing sensation indicates that the graft is patent. In addition to palpating for a thrill, the nurse should auscultate for a bruit, the sound heard at a patent graft site, as well as for intact pulses distal to the graft site. B) Health care provider notified of graft occlusion. INCORRECT A palpable thrill and audible (with stethoscope) bruit over the graft site indicate that the graft is patent. The nurse should also assess the pulse distal to the graft site to ensure adequate circulation. C) Bruit intact and palpated. INCORRECT A bruit is the swishing sound heard when the graft site is auscultated. This should also be assessed when the graft is palpated. D) +4 bounding pulse palpated. INCORRECT This sensation does not reflect the client's pulse, although it is important for the nurse to assess the pulse distal to the graft.

21.

Which intervention should the nurse include in Louellen's plan of care? A) Regularly rotate IV insertion sites above and below the graft site. INCORRECT The extremity with the graft should not be used for venipuncture (starting IVs or drawing blood) or for blood pressure assessment. B) Empty and record the drainage from the graft tubing regularly. INCORRECT The graft tubing is internal, and there is no attached external drainage device. The surgical site should be assessed for bleeding. C) Perform sterile dressing changes at the dual-lumen catheter site. CORRECT Central vein insertion sites are major sources of nosocomial infection, and they should be cleaned weekly using a strict aseptic technique. D) Instruct lab personnel to obtain blood specimens from the dual-lumen catheter. INCORRECT This is not a safe intervention. Hemodialysis catheters are heparinized following dialysis treatments to prevent catheter thrombosis, and they require the removal of this heparinized solution using a strict aseptic technique. Use of these catheters between treatments for medication administration or blood samples is not advised due to the high risk for complications.

Client Teaching: Dietary Management

Louellen is tolerating dialysis well, and she is scheduled for discharge. The nurse completes discharge teaching for the goal, "Client will manage her diet effectively while receiving hemodialysis 3 times a week."

22. Which expected outcome should be included in the nurse's teaching plan? A) Client will identify the need to increase her sodium and fluid intake. INCORRECT The client receiving hemodialysis will more typically need to restrict sodium and fluid intake, rather than increase the amounts consumed. B) Client will identify the need to avoid fresh fruits and vegetables. INCORRECT

Because fresh fruits and vegetables provide much needed vitamins, they do not need to be avoided. However, those fruits that are high in potassium should not be eaten in excessive amounts. C) Client will select foods high in iron and calcium from a menu. CORRECT Clients with CKD are frequently anemic and hypocalcemic, requiring dietary supplementation with iron and calcium. D) Client will adhere to a high-protein diet. INCORRECT Clients on hemodialysis must frequently restrict protein intake. The client's BUN is monitored to ensure protein intake is sufficient, but not excessive.

23. What is the maximum amount of weight that Louellen should gain between each dialysis treatment? A) 2 kg of weight. INCORRECT This is not the correct amount of weight. B) 1.5 kg of weight. CORRECT The goal for hemodialysis clients is to keep their interdialytic (between dialysis treatments) weight gain under 1.5 kg. C) 2.5 kg of weight. INCORRECT This is not the correct amount of weight. D) 3 kg of weight. INCORRECT This is not the correct amount of weight.

Kidney Transplantation

After receiving hemodialysis for about a year, Louellen is scheduled to receive a kidney transplant from her older brother. Following surgery, Louellen is transferred to the Surgical Intensive Care Unit. She is drowsy but awakens easily. She is able to swallow sips of water. Her incision is clean, dry, and intact.

24. Which nursing assessment has the highest priority during the first 24-hour postoperative period? A) Range of motion. INCORRECT Although an important assessment parameter, range of motion is not the highest priority. B) Vital signs. CORRECT Vital signs should be monitored frequently to assess for postoperative bleeding, infection, or organ rejection. C) Bowel sounds. INCORRECT Although an important assessment parameter, the return of bowel sounds in the first 24 hours is not the highest priority. D) Pedal pulses. INCORRECT Although an important assessment parameter, pedal pulses are not the highest priority.

25. Which intervention should be included in the plan of care during the immediate postoperative period? A) Encourage Louellen to use the incentive spirometer daily. INCORRECT Louellen should use the incentive spriometer at least every 2-4 hours to prevent complications from immobility such as pneumonia. B) Monitor Louellen's nasogastric tube every 4 hours. INCORRECT The client usually does not have a nasogastric tube in place after this surgery. If one is present, it should be monitored more frequently than every 4 hours. C) Monitor Louellen's urinary output hourly using an urimeter. CORRECT A kidney from a living donor related to the client usually begins to function immediately after surgery and may produce large amounts of dilute urine. Therefore, the output should be closely monitored.

D) Assess Louellen's surgical incision every shift. INCORRECT The surgical incision should be assessed at least every 2 hours in the immediate postoperative period.

Immunosuppressive Agents

Louellen's postoperative medications include immunosuppressive agents, which are used to reduce the risk of organ rejection.
Azathioprine (Imuran) 3 mg/kg IV daily. Cyclosporine (Sandimmune) 4 mg/kg IV daily. Solu-Medrol 60 mg IV every 6 hours.

26. The nursing is preparing to give Louellens medications. The cyclosporine (Sandimmune) comes in a vial with 50 mg/ml. Louellen weighs 132 lbs. How many milliliters of the medication should the nurse draw up? (Enter numerical value only. If rounding is necessary, round to the whole number.)
5

CORRECT D/H x V = X 132 lbs./2.2 lbs per kg = 60 kg 60 kg x 4 mg/kg = 120 mg 120 mg x 1 ml/50 mg = 4.8 ml

27. Which nursing diagnosis has the greatest priority when caring for a client receiving immunosuppressive agents? A) Risk for infection. CORRECT Suppression of the normal immune response causes leukopenia that can reduce the client's ability to fight infection, resulting in the potential for life-threatening sepsis. B) Fatigue. INCORRECT

Immunosuppressive agents can cause fatigue, but this is not the highest priority. C) Pain. INCORRECT Immunosuppressive agents such as Imuran can cause arthralgia, but this is not the highest priority. D) Diarrhea. INCORRECT Immunosuppressive agents such as cyclosporine can cause diarrhea, but this is not the highest priority.

28. Which interventions are important to include in Louellen's plan of care while she is receiving multiple immunosuppressants? (Select all that apply. To proceed, de-select any incorrect answer(s) and try again.) A) Change the IV site daily. INCORRECT Although the IV site should be monitored frequently for signs of phlebitis and infection, IV site changes should be performed following CDC guidelines. Excessive IV starts can be a source of infection. B) Have all staff and visitors wash their hands every time they enter her room. CORRECT Handwashing is one of the best ways to prevent the spread of infection. C) Reinforce, but do not routinely change any dressings. INCORRECT Dressings should be changed regularly, which allows inspection of the wound for signs of infection. Strict aseptic technique should be used to reduce the risk of infection. D) Restrict Louellen's activity to bedrest with use of the bedside commode. INCORRECT Since Louellen is at high risk for infection, activity and mobility should be encouraged to prevent the complications of immobility, such as atelectasis and pneumonia. Louellen should be assisted with mobility as needed since she is also at risk for injury. E) Instruct visitors that fresh flowers should not be taken into the room. CORRECT Fresh flowers, plants, and fruits are a source of bacteria and should be restricted from the client's room. In addition, visitors should be restricted to healthy adults, and extra precautions should be taken to avoid sharing hospital equipment and to ensure a clean room environment.

Management Issues: Priorities & Delegation

When Louellen is transferred from the Surgical Intensive Care Unit (SICU) back to the Surgical Nursing Care Unit, the nurse receives report on her condition. The report includes information that Louellen's IV needs to be converted to a saline lock and that her urinary catheter needs to be removed. During the nursing assessment, Louellen reports that she is experiencing incisional pain from all the activity and that the tape on her surgical dressing became loose during the transfer.

29. Which action should the nurse implement first? A) Change the surgical dressing. INCORRECT Since only the tape is loose, this is not the highest priority intervention. B) Remove the indwelling catheter. INCORRECT This action is a low priority and one that can increase the client's discomfort temporarily as the catheter is pulled from the bladder. It should be deferred until the client's higher priority need has been addressed. C) Administer an analgesic. CORRECT This intervention will reduce the client's pain and anxiety. It will also reduce discomfort when other procedures such as a dressing change are performed. D) Convert the IV to a saline lock. INCORRECT Converting the IV to a saline lock is a low priority at this time.

30. Which action can be delegated to the unlicensed assistive personnel (UAP)? A) Change the surgical dressing. INCORRECT UAPs do not routinely change surgical dressings since this skill requires the expertise of the nurse.

B) Administer an analgesic. INCORRECT UAPs do not administer medications. C) Convert the IV to a saline lock. INCORRECT This is a procedure requiring knowledge and skills beyond the scope of practice of a UAP. D) Remove the indwelling catheter. CORRECT This task may be delegated to the UAP since it is not an invasive procedure requiring the expertise of the nurse.

A Complication Occurs

One week after surgery, Louellen is discharged home. Three days later, she calls the nurse to report that she is experiencing more pain than she thinks she should be having.

31. What is the best initial response by the nurse? A) "The health care provider will need to call you back later if you need more pain medication." INCORRECT The nurse first needs to obtain additional information. B) "You may have developed a tolerance to your pain medication." INCORRECT This is not the best response, since the nurse has not obtained adequate data to make this determination. C) "Describe the location and type of pain you are having." CORRECT The nurse needs to obtain additional data to help determine the nature of the problem. D) "Going home often causes anxiety, which can increase your pain." INCORRECT This is not the best response since the nurse has not obtained adequate data to make this determination.

In response to the nurse's questions, Louellen states she feels very sore over her kidney area and she cannot remember voiding in the last 24 hours.

32. Which instructions should the nurse give Louellen? A) Increase her fluid intake and report any increase in her weight. INCORRECT These interventions do not address Louellen's symptoms. B) Monitor her temperature and report a fever over 101 F. INCORRECT The presence of a fever requires further investigation by the nurse because it can be a symptom of both infection and rejection, which are treated very differently. C) Advise her to come to the clinic right away for further evaluation. CORRECT Louellen is exhibiting symptoms consistent with organ rejection. She needs immediate assessment and evaluation for this potentially fatal complication. The nurse should assess for kidney pain, oliguria or anuria, hypertension, lethargy, fever, and fluid retention, as well as increased serum BUN, creatinine, and potassium. D) Take her prescribed diuretic and analgesic and record when she voids. INCORRECT Louellen is exhibiting symptoms that require a different intervention.

Therapeutic Communication: Grief Response

Louellen returns to the clinic, where her vital signs are: T 100.6 F, P 88, R 24, BP 178/96. A renal scan is performed, and it is determined that Louellen is experiencing acute organ rejection. Three types of rejection can occur after transplant: hyperacute, acute, and chronic.
Hyperacute rejection occurs within the first 48 hours after transplantation and requires

immediate removal of the transplanted kidney. Acute rejection occurs up to 2 years after surgery, most commonly within the first 2 weeks. It can often be managed effectively with increased doses of immunosuppressive medications.

 Chronic rejection is a gradual process, occurring over a period of months to years.

Conservative management, including a careful balance of fluid and protein intake helps control the rejection, but the eventual outcome is the need for dialysis. Louellen is started on a regimen of high-dose immunosupressants. During the acute rejection period, Louellen's brother states to the nurse, "She can't be having a rejection; I gave up my kidney for her. The doctors must have messed up something. I'll sue every one of them if this doesn't work."

33. What is the best response by the nurse? A) "Your obvious anger will not help Louellen now." INCORRECT Admonishing Louellen's brother is a block to further communication. B) "Don't blame the health care providers. They're doing everything possible." INCORRECT Giving advice is a block to further communication. C) "This is a very difficult time for you and your family." CORRECT Acknowledgment of the stress being experienced will encourage the brother to continue to express his feelings. D) "Why do you think the health care providers are at fault?" INCORRECT Asking "why" places the brother on the defensive and is a block to further communication.

The nurse recognizes that Louellen's brother is grieving. Stages in the grief process include denial, anger, bargaining, depression, and acceptance. The nurse can offer support and encouragement during each of these stages. Louellen's brother is experiencing anger.

34. What action should the nurse implement? A) Reassure the brother that this stage of grieving will end soon. INCORRECT This may be false reassurance. Some individuals remain in a stage of grief for prolonged periods of time.

B) Encourage the expression of anger in a non-harmful manner. CORRECT Anger is a normal, healthy response to loss. The nurse should help the brother find a way to express his anger that is not harmful to himself or others. Avoiding the expression of anger may result in the anger turning inward, causing depression or self-harm. C) Instruct the brother to avoid expressing feelings of anger to others. INCORRECT This is not the best recommendation concerning anger. D) Remind the brother that anger is damaging and unhealthy. INCORRECT While this is true, it will not help the client's brother and can close communication channels.

Case Outcome

Louellen's brother is able to share his frustration and anger with other family members. He physically vents his anger by tearing down an old fence. The medical regimen of immunosuppressants is successful in reversing the organ rejection, and Louellen is discharged home with the support of her family and the home care nursing agency.