CS 4 - Shortness of Breath, Edema, and Decreased Urine Output Flashcards
Ms. J is a 63-year-old woman who is admitted directly to the medical unit after visiting
her health care provider (HCP) because of shortness of breath and increased swelling in
her ankles and calves. She is being admitted with a diagnosis of chronic kidney disease.
Ms. J states that her symptoms have become worse over the past 2 to 3 months and that
she uses the bathroom less often and urinates in small amounts. Her medical history
includes hypertension (30 years), coronary artery disease (18 years), type 2 diabetes
(14 years), appendectomy at age 28, cataract surgery to the left eye 2 years ago and
right eye 1 year ago, and four pregnancies with healthy births. She also has
gastroesophageal reflux disease (GERD), which is controlled with over-the-counter
ranitidine 75 mg as needed.
Ms. J’s vital sign values on admission were as follows:
Blood pressure 162/96 mm Hg
Heart rate 88 beats/min
O 2 saturation 89% on room air
Respiratory rate 28 breaths/min
Temperature 97.8°F (36.6°C)
The patient is to be placed on oxygen at 2 L/min via nasal cannula. Admission
laboratory tests for which patient samples are to be collected on the unit include serum
electrolyte levels, kidney function tests, complete blood count, and urinalysis. A 24-
hour urine collection for determination of creatinine clearance has also been ordered.
Which patient admission tasks should the nurse delegate to the experienced
unlicensed assistive personnel (UAP)? Select all that apply.
1. Check vital signs every 4 hours.
2. Record accurate intake and output.
3. Place a saline lock in left forearm.
4. Check oxygen saturation by pulse oximetry.
5. Teach the patient the importance of keeping oxygen in place.
6. Check and record the fingerstick blood glucose before lunch.
Ans: 1, 2, 4, 6 Checking vital signs and recording intake and output fall within
the scope of practice for any UAP. An experienced UAP will have been
taught to use pulse oximetry to check oxygen saturation and to use a
glucometer to check a patient’s fingerstick blood glucose. However, in
Canada, glucose monitoring is considered an advanced skill and would not
be performed by UAP. Placing an IV line and teaching require additional
education and training that are more within the scope of practice for a
licensed nurse. Focus: Delegation, Supervision.
Ms. J is a 63-year-old woman who is admitted directly to the medical unit after visiting
her health care provider (HCP) because of shortness of breath and increased swelling in
her ankles and calves. She is being admitted with a diagnosis of chronic kidney disease.
Ms. J states that her symptoms have become worse over the past 2 to 3 months and that
she uses the bathroom less often and urinates in small amounts. Her medical history
includes hypertension (30 years), coronary artery disease (18 years), type 2 diabetes
(14 years), appendectomy at age 28, cataract surgery to the left eye 2 years ago and
right eye 1 year ago, and four pregnancies with healthy births. She also has
gastroesophageal reflux disease (GERD), which is controlled with over-the-counter
ranitidine 75 mg as needed.
Ms. J’s vital sign values on admission were as follows:
Blood pressure 162/96 mm Hg
Heart rate 88 beats/min
O 2 saturation 89% on room air
Respiratory rate 28 breaths/min
Temperature 97.8°F (36.6°C)
The patient is to be placed on oxygen at 2 L/min via nasal cannula. Admission
laboratory tests for which patient samples are to be collected on the unit include serum
electrolyte levels, kidney function tests, complete blood count, and urinalysis. A 24-
hour urine collection for determination of creatinine clearance has also been ordered.
During admission assessment, Ms. J has all of these findings. For which
finding should the nurse notify the HCP immediately?
1. Bilateral pitting ankle and calf edema rated + 2
2. Crackles in both lower and middle lobes
3. Dry and peeling skin on both feet
4. Faint but palpable pedal and post-tibial pulses
Ans: 2 All of these findings are important, but only the presence of crackles in
both lungs is urgent because it signifies fluid-filled alveoli and interruption of
adequate gas exchange and oxygenation, worsening of the patient’s
condition, and possibly pulmonary edema. The patient’s peripheral edema is
not new. The faint pulses are most likely caused by the presence of peripheral
edema. The dry and peeling skin is a result of chronic diabetes and merits
careful monitoring to prevent infection, but it is not immediately urgent.
Focus: Prioritization.
Ms. J is a 63-year-old woman who is admitted directly to the medical unit after visiting
her health care provider (HCP) because of shortness of breath and increased swelling in
her ankles and calves. She is being admitted with a diagnosis of chronic kidney disease.
Ms. J states that her symptoms have become worse over the past 2 to 3 months and that
she uses the bathroom less often and urinates in small amounts. Her medical history
includes hypertension (30 years), coronary artery disease (18 years), type 2 diabetes
(14 years), appendectomy at age 28, cataract surgery to the left eye 2 years ago and
right eye 1 year ago, and four pregnancies with healthy births. She also has
gastroesophageal reflux disease (GERD), which is controlled with over-the-counter
ranitidine 75 mg as needed.
Ms. J’s vital sign values on admission were as follows:
Blood pressure 162/96 mm Hg
Heart rate 88 beats/min
O 2 saturation 89% on room air
Respiratory rate 28 breaths/min
Temperature 97.8°F (36.6°C)
The patient is to be placed on oxygen at 2 L/min via nasal cannula. Admission
laboratory tests for which patient samples are to be collected on the unit include serum
electrolyte levels, kidney function tests, complete blood count, and urinalysis. A 24-
hour urine collection for determination of creatinine clearance has also been ordered.
Which task associated with the patient’s 24-hour urine collection is
appropriate for the nurse to delegate to the UAP?
1. Instructing Ms. J to collect all urine with each voiding
4702. Teaching Ms. J the purpose of collecting urine for 24 hours
3. Ensuring that all of Ms. J’s urine collected for the test is kept on ice
4. Assessing Ms. J’s urine for color, odor, and sediment
Ans: 3 Teaching, instructing, and assessing are all functions that require
additional education and preparation appropriate to the scope of practice for
professional nurses. Providing the patient with ice for the urine collection and
reminding the patient to collect her urine fit the scope of practice of the UAP.
Remember that the UAP can remind a patient about anything that has
already been taught. Focus: Delegation, Supervision.
Ms. J is a 63-year-old woman who is admitted directly to the medical unit after visiting
her health care provider (HCP) because of shortness of breath and increased swelling in
her ankles and calves. She is being admitted with a diagnosis of chronic kidney disease.
Ms. J states that her symptoms have become worse over the past 2 to 3 months and that
she uses the bathroom less often and urinates in small amounts. Her medical history
includes hypertension (30 years), coronary artery disease (18 years), type 2 diabetes
(14 years), appendectomy at age 28, cataract surgery to the left eye 2 years ago and
right eye 1 year ago, and four pregnancies with healthy births. She also has
gastroesophageal reflux disease (GERD), which is controlled with over-the-counter
ranitidine 75 mg as needed.
Ms. J’s vital sign values on admission were as follows:
Blood pressure 162/96 mm Hg
Heart rate 88 beats/min
O 2 saturation 89% on room air
Respiratory rate 28 breaths/min
Temperature 97.8°F (36.6°C)
The patient is to be placed on oxygen at 2 L/min via nasal cannula. Admission
laboratory tests for which patient samples are to be collected on the unit include serum
electrolyte levels, kidney function tests, complete blood count, and urinalysis. A 24-
hour urine collection for determination of creatinine clearance has also been ordered.
The results of Ms. J’s 24-hour urine collection reveals a creatinine clearance of
65 mL/min (1.09 mL/sec). How does the nurse best interpret this finding?
1. Creatinine clearance is lower than normal.
2. Creatinine clearance is higher than normal.
3. Creatinine clearance is within normal range.
4. Creatinine clearance indicates adequate kidney function.
Ans: 1 The normal creatinine clearance is 107 to 139 mL/min for men (1.78–
2.32 mL/sec) and 87 to 107 mL/min (1.45–1.78 mL/sec) for women tested with
a 24-hour urine collection. A low result indicates that the kidneys are
functioning at a lower than expected level. The patient has chronic kidney
disease. Focus: Prioritization; Test Taking Tip: The nurse should be familiar
with the normal values of frequently ordered lab tests, as well as main causes
and risks of high and low levels.
Which risk factors in Ms. J's history indicate increased risk for chronic kidney disease (CKD)? Select all that apply. 1. GERD 2. Hypertension 3. Four pregnancies 4. Type 2 diabetes 5. Coronary artery disease (CAD) 6. Cataracts
Ans: 2, 4, 5 Major risk factors for CKD include hypertension and diabetes.
CAD has a related pathophysiology to hypertension. Pregnancy, cataracts,
and GERD are not risk factors for CKD. Focus: Prioritization.
The RN reviews Ms. J’s laboratory results. Which laboratory finding is of
most concern?
1. Serum potassium level of 7.1 mEq/L (7.1 mmol/L)
2. Serum creatinine level of 7.3 mg/dL (645 μmol/L)
3. Blood urea nitrogen level of 180 mg/dL (64.3 mmol/L)
4. Serum calcium level of 7.8 mg/dL (1.95 mmol/L)
Ans: 1 A patient with a serum potassium level of 7 to 8 mEq/L (7-8 mmol/L)
or higher is at risk for electrocardiographic changes and fatal dysrhythmias.
The HCP should be notified immediately about this potassium level.
Although the serum creatinine and blood urea nitrogen levels are high, these
levels are commonly reached before patients experience symptoms of chronic
kidney disease (CKD). The serum calcium level is low but not life
threatening. Keep in mind that there is an inverse relationship between
calcium and phosphorus, so when calcium is low, expect phosphorus to be
475high. Focus: Prioritization.
Which medication should the nurse be prepared to administer to lower the
patient’s potassium level?
1. Furosemide 40 mg IV push
2. Epoetin alfa 300 units/kg subcutaneously
3. Calcium 1 tablet PO
4. Sodium polystyrene sulfonate 15 g PO
Ans: 4 Sodium polystyrene sulfonate removes potassium from the body by
exchanging sodium for potassium in the large intestine. Diuretics such as
furosemide generally do not work well in chronic kidney failure. The patient
may need a calcium supplement and subcutaneous epoetin alfa; however,
these drugs do nothing to decrease potassium levels. Focus: Prioritization.
Ms. J states that she feels increasingly short of breath. The nurse team leader
is supervising an LPN/LVN and a UAP. Which nursing care action for Ms. J
should be most appropriately assigned to the LPN/LVN?
1. Checking for residual urine with the bedside bladder scanner
2. Planning restricted fluid amounts to be given with meals
3. Assessing breath sounds for increased bilateral crackles
4. Discussing renal replacement therapies with the patient
Ans: 1 Checking residual urine with a bedside bladder scanner is within the
scope of practice of the LPN/LVN, who would remain under the supervision
of the RN. Planning care and discussing options such as renal replacement
therapies require additional education and training, which are within the
scope of practice for the professional RN. Although in many acute care
hospitals, LPN/LVNs auscultate breath sounds as a part of their observations,
RNs follow up for overall assessment and synthesis of data. Because Ms. J is a
potentially unstable patient with respiratory changes that may indicate
worsening of her condition, the more appropriate person to assess her lung
sounds would be the RN. Focus: Assignment, Supervision.
The team leader RN observes the UAP perform all of these actions for Ms. J.
For which actions must the RN intervene? Select all that apply.
4711. Assisting the patient to replace her oxygen nasal cannula
2. Checking vital signs after the patient has had something cold to drink
3. Ambulating with the patient to the bathroom and back
4. Increasing the patient’s oxygen flow rate by nasal cannula from 2 to 4 L/min
5. Washing the patient’s back, legs, and feet with warm water
6. Reminding Ms. J to perform prescribed incentive spirometry every hour
while awake
Ans: 2, 4 Checking vital signs usually includes measuring oral body
temperature. Because the patient just finished drinking fluids, an oral
temperature measurement would be inaccurate at this time. If the fluids were
cold, the temperature would be falsely low; if the fluids were hot, the
temperature would be falsely high. Changing the oxygen flow rate without
prescription or instruction is not acceptable practice. All of the other actions
are appropriate and within the scope of practice of the UAP. A UAP’s scope
of practice includes reminding patients of content that has already been
taught. Focus: Delegation, Supervision.
The RN team leader assigns the LPN/LVN to give Ms. J’s 9:00 am oral
medications. Which key instruction or action will be most important that the
RN give the LPN/LVN regarding administering Ms. J’s atenolol 50-mg tablet?
1. Give this drug with just a few swallows of water.
2. Ask the patient if she has been taking a diuretic at home.
3. Instruct the patient to use the bedside commode.
4. Check the patient’s heart rate and blood pressure.
Ans: 4 Atenolol is a beta-blocker drug with actions that slow the heart rate
and decrease the blood pressure. HCPs often have blood pressure (BP) and
heart rate (HR) guidelines (e.g., low BP and/or HR) for when to give and
when to hold these drugs. The nurse should instruct the patient to call for
help getting out of bed when the drug is newly prescribed or if the drug
results in dizziness and syncope symptoms. The other instructions and
actions may be included in the patient’s care but will not affect the
administration of atenolol. Focus: Prioritization.
Ms. J’s care plan includes the nursing concern, excess fluid volume. What
interventions are appropriate for this nursing concern? Select all that apply.
1. Measure weight daily.
2. Monitor daily intake and output.
3. Restrict sodium intake with meals.
4. Restrict fluid to 1500 mL plus urine output.
5. Assess for crackles in the lungs every shift.
6. Check for peripheral edema and note any increase.
Ans: 1, 2, 3, 5, 6 The usual fluid restriction for patients with chronic kidney
failure is 500 to 700 mL plus urine output. All of the other actions are
appropriate for a patient with fluid overload. Remember that it is essential for
the nurse to compare findings with previous shifts and days to determine if
symptoms are worsening. Focus: Prioritization.
The RN is delegating and assigning care for Ms. J related to her type 2
diabetes. Which action by the RN indicates that the team leader needs to
intervene?
1. RN delegates fingerstick glucose check to newly hired UAP.
2. RN assigns administering morning dose of metformin to the LPN/LVN.
3. RN refers the patient to a dietitian for education about a diabetic diet.
4. RN assesses condition of patient’s feet daily.
Ans: 1 The newly hired UAP would need to be taught how to use a
glucometer and perform a fingerstick before having this task delegated to
him or her. All of the other care tasks are appropriate to the staff members.
Focus: Delegation, Assignment, Supervision.
After discussing renal replacement therapies with the HCP and nurse, Ms. J
is considering hemodialysis (HD). Which statement indicates that Ms. J needs
additional teaching about HD?
1. “I will need surgery to create an access route for HD.”
2. “I will be able to eat and drink what I want after I start dialysis.”
3. “I will have a temporary dialysis catheter for a few months.”
4. “I will be having dialysis three times every week.”
Ans: 2 Even after beginning HD, patients are still required to restrict fluid
476intake. In addition, patients on HD have nutritional restrictions (e.g., protein,
potassium, phosphorus, sodium restrictions). All of the other patient
statements indicate an appropriate understanding of HD. Focus:
Prioritization.
The RN is precepting a new nurse orientating to the unit, who is providing
care for Ms. J after her return from surgery to create a left forearm access for
dialysis. Which action by the orienting nurse requires that the preceptor
472intervene?
1. Monitoring the patient’s operative site dressing for evidence of bleeding
2. Obtaining a blood pressure reading by placing the cuff on the right arm
3. Drawing blood for laboratory studies from the temporary dialysis line
4. Administering acetaminophen with codeine PO for moderate postoperative
pain
Ans: 3 Temporary dialysis lines are to be used only for HD. The preceptor
nurse should stop the new nurse before the temporary HD system is
interrupted. Breaking into the system increases the risk for complications
such as infection. The blood pressure should always be assessed on the
nondialysis arm. Postoperative patients should always be monitored for
bleeding. Acetaminophen with codeine, when ordered by the HCP, is an
appropriate analgesic for moderate to severe pain. Focus: Assignment,
Supervision; Test Taking Tip: It’s essential that the nurse know the key
principles for care of a patient after a surgical procedure. In this case, with a
temporary HD line in place, the most important aspect is preventing
infection, which is a risk whenever the system is interrupted.
Assessment of Ms. J after dialysis reveals all of these findings. Which
assessment finding necessitates immediate notification of the HCP?
1. Weight decrease of 4.5 lb (2 kg)
2. Systolic blood pressure decrease of 14 mm Hg
3. Decreased level of consciousness
4. Small blood spot near the center of the dressing
Ans: 3 Changes in level of consciousness during or after HD can signal
dialysis disequilibrium syndrome, a life-threatening situation that requires
early recognition and treatment with anticonvulsants. This should be
immediately reported to the HCP so that appropriate treatment can be
prescribed. Decreases in weight and blood pressure are to be expected as a
result of dialysis therapy. A small amount of drainage is common after HD.
Focus: Prioritization.
