The nurse is caring for a 32-year-old female patient coming to the clinic with peripheral edema, periorbital edema, and flank pain.
This case consists of six clinical judgment questions. Read each question carefully and select the best answer(s). Use the chart to help answer the question. The chart is dynamic and may change as the case progresses.
Medical/Surgical history: Systemic lupus erythematosus (SLE) x 12 years, controlled with glucocorticoids, diabetes mellitus x 2 years, recurring urinary tract infections (UTIs). Surgical history includes C-sections x 2.
Social history: Married with 2 healthy children. Works full time as an office manager. Denies use of alcohol, drugs, or tobacco.
Family history: Mother also had SLE, died at age 55 from complications of renal failure. Father is alive and healthy.
Physical Assessment: Alert and oriented, moves all extremities, grips and pushes strong, PERRLA. Lungs with fine crackles, bilaterally, no shortness of breath. S1, S2 heart sounds with murmur. 3+ radial and pedal pulses. 4+ edema of the lower legs, ankles and feet, 2+ edema of the fingers and hands, periorbital edema present. Pain with percussion of the costovertebral angle.
Medications: Prednisone 5 to 10 mg daily, titrated to symptoms; metformin 500 mg by mouth twice a day; NSAIDs for pain, PRN.
A 32-year-old woman came to the clinic today for swelling of the legs, hands, and face that has increased over the last week. Flank pain present and described as “a constant nagging ache that does not go away.” States pain is 4 on a 0 to 10 scale.
Arrived at the emergency department by private vehicle from the clinic. Admission labs drawn.
Urinalysis results consistent with glomerulonephritis. Labs demonstrate renal failure. Patient admitted to medical-surgical unit.
Weight up 1 kg overnight. Lungs with bilateral crackles, and shortness of breath noted with minimal activity. Respiratory rate 24 breaths/min. SpO2 95% on 2L/nasal cannula. Cardiac monitor shows sinus tachycardia with peaked T waves. Intermittently disoriented.
Returned from interventional radiology after the placement of a left subclavian central venous catheter for hemodialysis tomorrow. Dressing clean, dry, and intact. Family and patient asking many questions about hemodialysis. Teaching provided.
Morning VS recorded; taken for hemodialysis via wheelchair.
Returned from hemodialysis, assessment performed
Temp 99.2° F (37.3° C)
HR 101 bpm; regular
RR 18 breaths/min
SpO2 95% on room air
BP 187/99 mm Hg (MAP 128)
Temp 100.2° F (37.8° C)
HR 106 bpm; regular
RR 18 breaths/min
SpO2 94% on room air
BP 192/102 mm Hg (MAP 132)
Temp 98.2° F (36.7° C)
HR 116 bpm; regular
RR 22 breaths/min
SpO2 94% on 2 L/nasal cannula
BP 190/100 mm Hg (MAP 130)
WBC 14.2 103/mm3 (4.5-11.1 103/mm3)
RBC 3.0 million/mm3 (3.61-5.11 million/mm3)
Platelets 395,000 /mm3 (150,000-450,000/mm3)
BUN 45 mg/dL (8-21 mg/dL)
Creatinine 3.2 mg/dL (0.5-1.2 mg/dL)
Sodium 135 mEq/L (135-145 mEq/L)
Potassium 5.6 mEq/L (3.5-5.0 mEq/L)
Glucose 260 mg/dL (65-99 mg/dL)
A1c 9.9% (6.5% or lower)
pH 7.29 (7.35-7.45)
PaO2 72 mm Hg (80-95 mm Hg)
PaCO2 31 mm Hg (35-45 mm Hg)
HCO3- 19 mEq/L (22-26 mEq/L)
Question 1 of 6
The nurse reviews the patient’s record. Select to highlight the areas that are the most concerning at this time.
Physical Assessment: Alert and oriented, moves all extremities, // grips and pushes strong, PERRLA. // Lungs with fine crackles, // bilaterally, no shortness of breath. // S1, S2 heart sounds with murmur. // 3+ radial and pedal pulses. //4+ edema of the lower legs, ankles and feet, //2+ edema of the fingers and hands, periorbital edema present. //Pain of the costovertebral angle. //
Temp 99.2° F (37.3° C) //
HR 101 bpm; regular//
RR 18 breaths/min//
SpO2 95% on room air//
BP 187/99 mm Hg (MAP 128) //
Question 2 of 6
The nurse is concerned about the patient’s renal function. For each patient finding, specify if the finding is consistent with the disease process of glomerulonephritis, urinary tract infection, or renal failure. Select all that apply in each row.
Urinary Tract Infection
Question 3 of 6
The nurse is planning care. Drag the nursing actions that should be included to the box on the right. Be sure to drag all that apply.
Encourage oral fluids
Strict intake and output
Skin assessment each shift
Provide high-protein snacks
Measurement of abdominal girth and extremity size
Question 4 of 6
The nurse is reviewing the most recent findings. Complete the sentences.
The patient has crackles in the lungs because of
1 too much activity
2 low protein levels
3 high potassium level
4 fluid volume excess
, yet the tachypnea is more likely to be due to the
1 secondary lung infection
2 low oxygen levels
3 metabolic acidosis
4 history of smoking
. Because of the cardiac rhythm, the nurse should evaluate the most recent
2 blood pressure
3 potassium level
4 calcium level
Question 5 of 6
Which items should the nurse teach the patient and family about dialysis? Select all that apply.
Need for fluid restrictions
Close monitoring of urine output
Avoid acetaminophen for pain control
Normal protein in the diet
Avoid nephrotoxic substances
Decrease sodium in the diet
Signs of polycythemia
Increase foods high in phosphorus
Question 6 of 6
The patient returns from a 4-hour hemodialysis treatment. For each evaluation, specify whether the finding is anticipated or not anticipated. Select one option in each row.
Decrease in blood pressure
Increase in respiratory rate
Decrease in temperature
Increase in SpO2
Increase in weight
Decreased sodium level
Decreased potassium level
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