81.

2. Because hypotension is a complication

associated with peritoneal dialysis, the nurse
records intake and output, monitors vital signs,
and observes the clients behavior. The nurse also
encourages visiting and other diversional activities.
A client on peritoneal dialysis does not need to be
placed in a bed with padded side rails or kept on
NPO status.
CN: Reduction of risk potential;
CL: Synthesize

82.

1, 2, 4, 5. Broad-spectrum antibiotics may be

administered to prevent infection when a peritoneal
catheter is inserted for peritoneal dialysis. If peritonitis
is present, antibiotics may be added to the
dialysate. Aseptic technique is imperative. Peritonitis,
the most common and serious complication
of peritoneal dialysis, is characterized by cloudy
dialysate drainage, diffuse abdominal pain, and
rebound tenderness.
CN: Safety and infection control;
CL: Synthesize

83.

2. Weight loss is expected because of the

removal of fl uid. The clients weight before and
after dialysis is one measure of the effectiveness of
treatment. Blood pressure usually decreases because
of the removal of fl uid. Hematuria would not occur
after completion of peritoneal dialysis. Dialysis only
minimally affects the damaged kidneys ability to
manufacture urine.
CN: Reduction of risk potential;
CL: Evaluate

84.

3. A client in renal failure develops hyperphosphatemia

that causes a corresponding excretion
of the bodys calcium stores, leading to renal
osteodystrophy. To decrease this loss, aluminum
hydroxide gel is prescribed to bind phosphates in
the intestine and facilitate their excretion. Gastric
hyperacidity is not necessarily a problem associated
with chronic renal failure. Antacids will not prevent
Curlings stress ulcers and do not affect metabolic
acidosis.
CN: Pharmacological and parenteral
therapies; CL: Evaluate

85.

4. Aluminum hydroxide gel (Amphojel) is

administered to bind the phosphates in ingested
foods and must be given with or immediately after
meals and snacks. There is no need for the client
to take it on a 24-hour schedule. It is not administered
to treat hyperacidity in clients with chronic
renal failure and therefore is not prescribed between
meals.
CN: Pharmacological and parenteral
therapies; CL: Evaluate

86.

1. Magnesium is normally excreted by the

kidneys. When the kidneys fail, magnesium can
accumulate and cause severe neurologic problems.
Milk of magnesia is harsher than Metamucil, but
magnesium toxicity is a more serious problem. A
client may fi nd both milk of magnesia and Metamucil
unpalatable. Milk of magnesia is not high in
sodium.
CN: Pharmacological and parenteral
therapies; CL: Apply

87.

2. Uremia can cause decreased alertness, so

the nurse needs to validate the clients comprehension
frequently. Because the clients ability to concentrate
is limited, short lessons are most effective.
If family members are present at the sessions, they
can reinforce the material. Written materials that the
client can review are superior to videotapes because
clients may not be able to maintain alertness during
the viewing of the videotape.
CN: Physiological adaptation;
CL: Synthesize

88.

3. Dietary management for clients with

chronic renal failure is usually designed to restrict
protein, sodium, and potassium intake. Protein
intake is reduced because the kidney can no longer
excrete the byproducts of protein metabolism. The
degree of dietary restriction depends on the degree
of renal impairment. The client should also receive
a high-carbohydrate diet along with appropriate
vitamin and mineral supplements. Calcium requirements
remain 1,000 to 2,000 mg/day.
CN: Basic care and comfort;
CL: Synthesize

89.

2. Altered sexual functioning commonly

occurs in chronic renal failure and can stress marriages
and relationships. Altered sexual functioning
can be caused by decreased hormone levels,
anemia, peripheral neuropathy, or medication. The
client should not decrease or avoid sexual activity
but instead should modify it. The client should rest
before sexual activity.
CN: Psychosocial adaptation;
CL: Synthesize

90.

2. The major benefi t of CAPD is that it

frees the client from daily dependence on dialysis
centers, health care personnel, and machines for
life-sustaining treatment. This independence is a
valuable outcome for some people. CAPD is costly
and must be done daily. Adverse effects and complications
are similar to those of standard peritoneal
dialysis. Peritoneal dialysis usually takes less time
but cannot be done at home.
CN: Reduction of risk potential;

CL: Apply

91.

3. Dietary restrictions with CAPD are fewer

than those with standard peritoneal dialysis because
dialysis is constant, not intermittent. The constant
slow diffusion of CAPD helps prevent accumulation
of toxins and allows for a more liberal diet. CAPD
does not work more quickly, but more consistently.
Both types of peritoneal dialysis are effective.
CN: Basic care and comfort;
CL: Synthesize

92.

1. Cloudy drainage indicates bacterial activity

in the peritoneum. Other signs and symptoms of
infection are fever, hyperactive bowel sounds, and
abdominal pain. Swollen legs may indicate heart
failure. Poor drainage of dialysate fl uid is probably
the result of a kinked catheter. Redness at the insertion
site indicates local infection, not peritonitis.
However, a local infection that is left untreated can
progress to the peritoneum.
CN: Reduction of risk potential;
CL: Analyze

The Client with Urinary Incontinence

93.

1, 2. Laughing may be a part of ones socialization,

so it should not be discouraged. In non-restricted
clients, a fl uid intake of at least 2 to 3 L/day
is encouraged; clients with stress incontinence may
reduce their fl uid intake to avoid incontinence at
the risk of developing dehydration and urinary tract
infections. Establishing a voiding schedule would
be more effective in the prevention of stress incontinence
rather than carrying incontinence pads.
Dietary irritants and natural diuretics, such as caffeine
and alcoholic beverages, may increase stress
incontinence. Kegel exercises strengthen the sphincter
and structural supports of the bladder.
CN: Health promotion and maintenance;
CL: Synthesize

94.

2. The history of three pregnancies is most

likely the cause of the clients current episodes of
stress incontinence. The clients fl uid intake, age, or
history of swimming would not create an increase in
intra-abdominal pressure.
CN: Reduction of risk potential;
CL: Analyze

95.

4. The primary goal of nursing care is to

decrease the number of incontinence episodes
and the amount of urine expressed in an episode.
Behavioral interventions (e.g., diet and exercise)
and medications are the nonsurgical management
methods used to treat stress incontinence. Without
surgical intervention, it may not be possible to
eliminate all episodes of incontinence. Helping the

client adjust to the incontinence is not treating the

problem. Clients with stress incontinence are not
prone to the development of urinary tract infection.
CN: Physiological adaptation;
CL: Synthesize

96.

2. Clients with stress incontinence are

encouraged to avoid substances, such as caffeine
and alcohol, that are bladder irritants. Emotional
stressors do not cause stress incontinence. It is most
commonly caused by relaxed pelvic musculature.
Wearing girdles is not contraindicated. Although
clients may want to limit physical exertion to avoid
incontinence episodes, they should be encouraged
to seek treatment instead of limiting their activities.
CN: Reduction of risk potential;
CL: Create

97.

3. A characteristic of urge incontinence is

involuntary urination with little or no warning. The
inability to empty the bladder is urine retention.
Loss of urine when coughing occurs with stress
incontinence. Frequent dribbling of urine is common
in male clients after some types of prostate surgery
or may occur in women after the development
of a vesicovaginal or urethrovaginal fi stula.
CN: Physiological adaptation;
CL: Analyze

98.

1. Instructing the client to void at regularly

scheduled intervals can help decrease the frequency
of incontinence episodes. Providing a bedside commode
does not decrease the number of incontinence
episodes and does not help the client who leads an
active lifestyle. Infections are not a common cause
of urge incontinence, so antibiotics are not an appropriate
treatment. Intermittent self-catheterization is
appropriate for overfl ow or refl ux incontinence, but
not urge incontinence, because it does not treat the
underlying cause.
CN: Physiological adaptation;
CL: Synthesize

Managing Care Quality and Safety

99.

4. Sensitivity to shellfi sh or iodine may cause

an anaphylactic reaction to the contrast material,
which contains iodine. Administering a cathartic
or antifl atulent will not prevent an anaphylactic
reaction to the contrast material. Keeping a client on
NPO status for 8 hours before the procedure is part
of the usual preparation for such a procedure to prevent
aspiration of food or fl uids if the client vomits
when lying on the X-ray table.

100.

1. The appropriate action would be to discard

the specimen and obtain a new one. Urine that is
allowed to stand at room temperature will become
alkaline, with multiplying bacteria. The specimen

should be examined within 1 hour after urination.

CN: Reduction of risk potential;
CL: Synthesize

101.

1, 2, 3, 4, 6. Before ordering and administering

packed RBCs, the nurse should assess the I.V.
site to make sure it has an 18G to 20G Angiocath.
The nurse should also ensure that normal saline
solution is used to prime the tubing to prevent
RBCs from adhering to the tubing. The client must
indicate informed consent for the procedure by
signing the consent form. The clients blood must
be typed to determine ABO blood typing and Rh
factor and ensure that the client receives compatible
blood. Cross-matching is done to detect the presence
of recipient antibodies to the donors minor
antigens. Vital signs provide a baseline reference for
continuous monitoring throughout the transfusion.
An identifi cation bracelet and red blood band are
essential for client identifi cation per facility policy.
Two nurses must double check the clients identifi
cation with the client listed on the unit of RBCs.
The transfusion should be started within 30 minutes
of the time that the RBC unit is checked out of the
blood bank. Thus, no blood should be kept in the
medication room before transfusion.
CN: Safety and infection control;
CL: Synthesize

102.

3. The correct technique for a clean-catch

urine culture specimen is to have the female client
clean the labia from front to back, void into the toilet,
and then void into the cup. The client does not
need to fully empty her bladder into the cup. It is
not necessary to catheterize the client to obtain the
specimen. The fi rst voided specimen of the day has
the highest bacterial counts.
CN: Basic care and comfort;
CL: Evaluate