img-download-app
img-download-app

The nurse is caring for a post-op client after renal artery bypass for an arterial occlusion. To promote the goal of effective kidney function, the nurse includes which intervention(s) in the plan of care?

Explanation

• By definition, Acute Kidney Injury (AKI) is an abrupt decrease (within 48 hours) in kidney function that includes an increase in serum creatinine (either an absolute increase of greater than 0.3 mg/dL or a percentage increase of 50%) or a decrease in urine output (less than 0.5 mL/kg/hour for more than 6 hours). It may be caused by disease or injury.  Kidney function usually returns to baseline if AKI is identified early and appropriately treated.

• To promote effective kidney function, the nurse should include interventions that support renal perfusion, monitor the patient's kidney function by evaluating labs and data being collected, and reporting noteworthy findings.

• Administering IV fluids ensures adequate fluid volume for circulation of oxygenated blood to the renal and peripheral tissues. 

• Maintaining strict I&O promotes the goal of effective tissue perfusion by collecting data on the progression and treatment of the acute kidney injury.

• Monitoring serial creatinine levels evaluates kidney function following response to treatment.

• Monitoring urine specific gravity is important. This measures the kidney’s ability to concentrate urine. In AKI, specific gravity is usually equal to or less than 1.010, indicating loss of ability to concentrate the urine. If urine specific gravity trends lower in the recovery phase, this requires reporting to the provider to facilitate evaluation and intervention.

• Blood and drainage may appear on dressings or beneath the site because of gravity. Monitoring for this is important, and it contributes toward the goal of kidney function by monitoring for complications that would compromise renal perfusion.

• Remember that “interventions” may include monitoring, evaluating, or observing. These are interventions when implemented to address patient problems already identified in the assessment phase.

Incorrect options:

• Evaluating the effectiveness of pain medication helps determine the adequacy of analgesia, but does not address kidney function directly.

 

 


 

Visit our website for other NCLEX topics now!
Related questions

The nurse is assisting the physician with a liver biopsy performed at the patient’s bedside. Which of the following should the nurse do after the procedure is completed?

The home health nurse observes the nurse aide transfer a patient with hemiplegia from a sitting position on the bed to the wheelchair. Which of the following actions needs correction by the home health nurse? The aide

A nurse caring for a client on neutropenic precautions needs to be alert to which early sign, indicating a change in the client’s condition?

A patient who is scheduled for a bone marrow transplant is concerned about the cost of the procedure. How should the nurse respond?

Which of the following clinical findings would the nurse be most concerned with in a client with chronic kidney disease?

A 13-year-old patient has been diagnosed with impetigo, caused by Staphylococcus aureus, which is being treated with antibiotics. While doing a physical assessment, the nurse would expect to find skin lesions on which of the following areas of the body?

A patient attends a wound clinic for a foot ulcer that will not heal. The patient asks for an explanation as to why the ulcer is not healing. Which of the following diseases would have a negative impact on wound healing, and in turn would require further patient education by the nurse?

A nurse is implementing fluid resuscitation on a patient with full-thickness burns. Vital signs show a blood pressure of 85/55, pulse of 109, respiration rate of 22, and an hourly urine output of 15 ml. The nurse notifies the physician and expects which of the following interventions to be ordered?

A nurse is using the Braden scale to help predict a patient's pressure ulcer risk. The patient's sensory perception is very limited, she is occasionally moist, she is bedfast, her mobility is very limited, nutrition is adequate, and friction is a potential problem. What is this patient's total Braden score?

A patient received a bite wound from an animal and developed cellulitis as a result. The nurse explains to the patient that this infection is most likely caused by:

A nurse is monitoring the electrocardiogram (EKG) of a patient in the intensive care unit (ICU). The monitor shows a regular P to P interval with intermittent QRS waves that have regular intervals when occurring, but are often missing. The EKG demonstrates no correlation between P waves and QRS waves. The nurse knows that this indicates which of the following heart rhythms?

A patient presents in the emergency room (ER) with complaints of chest pain. The electrocardiogram (EKG) shows regular PR interval with a QRS wave missing every third beat. The nurse evaluates the EKG and recognizes this rhythm as which of the following? )

The nurse is caring for a patient that suddenly goes into uncontrolled atrial fibrillation. To determine if the patient has an adequate stroke volume, the nurse would assess for

The nurse is auscultating the heart of a patient with congestive heart failure. The nurse hears an extra sound with a very low pitch, immediately after the second heart sound (S2). The nurse interprets this as

The nurse is caring for a patient in the early stages of heart failure. The family is curious as to how the body adapts to heart failure. The nurse knows that during the early stages of heart failure, which specific compensatory mechanisms occur?

A newly diagnosed diabetic is receiving consultation about the disease process. The nurse explains that insulin is normally secreted from the

A nurse is caring for a patient who has left hemiparesis after a stroke. To avoid the risk of disuse syndrome, the nurse should do which of the following? 

A patient is scheduled for a computerized tomography (CT) scan. Which of the following is an appropriate statement by the nurse?

A nurse is working in the ER when a patient is brought in by ambulance after a motor vehicle accident. The patient has a neck brace in place and has blood on the face and down the torso. The patient is breathing and has a pulse that is rapid but palpable. The nurse knows the next intervention should be which of the following? 

A 46-year-old patient will undergo a bone marrow transplant and an informed consent form has been signed. The nurse is about to administer a sedative before the procedure when the patient says, "How many bones will be taken out?" What should the nurse do next?

A 72-year-old patient verbalized that he has very loud, overpowering ringing in both ears, intermittent hearing loss on the right side, and severe vertigo with nausea. The nurse assessing the patient suspects that he has

A patient is admitted to the inpatient unit with difficulty breathing, a productive cough, and audible wheezes. Which lab value should be reported to the physician immediately?

An overweight elderly patient with arthritis wants to control his disease and pain without the use of medications. Which of the following should the nurse include in the patient's care plan?

The nurse is examining a patient with systemic lupus erythematosus (SLE). Which of the following symptoms would the nurse expect?

A 38-year-old female patient comes in with complaints of double vision, visual loss, weakness, numbness of hands, fatigue, and tremors that have been worsening over the past several months. During admission, the nurse notes nystagmus, scanning speech, ataxia, muscular weakness, and incontinence. Considering these findings, the nurse suspects that the patient has

A patient with pancreatitis is at risk for developing a paralytic ileus. Which of the following assessment data indicates this complication?

A nurse is teaching a patient with hyperparathyroidism how to prevent hypercalcemia. The nurse should include which of the following in her medical counseling?

A nurse received an order to initiate early ambulation with a patient post appendectomy. The nurse recognizes this activity to be helpful in preventing possible complications associated with prolonged bed rest. To assist the patient to start walking after surgery, the nurse will:

A nurse is assessing a patient who has longstanding hypertension. The nurse knows that complications of hypertension are possibly arising when which of the following signs are noted?