The nurse is caring for a client in chronic renal failure who is admitted to the hospital to begin peritoneal dialysis. Which manifestation would the nurse need to report to the health care provider immediately?
1. Urine output of 10 mL over the past 4 hours
2. Potassium level of 5.9 mg/dL
3. Edema of the ankles bilaterally with 1+ pitting
4. Slight rales in the base of the right lung
Correct Answer: 2
The nurse would report unexpected or potentially dangerous findings to the primary care provider. A potassium level of 5.9 is significant, and would need to be reported immediately. Reduced urine output, mild edema of the ankles, or mild rales at the base of a lung are anticipated findings in a client with chronic renal failure prior to dialysis, and would not need to be reported.
You might also like to view...
The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?
a. Percussion is a useful tool for outlining the heart's borders. b. Percussion is easier in patients who are obese. c. Studies show that percussed cardiac borders do not correlate well with the true cardiac border. d. Only expert health care providers should attempt percussion of the heart.
The nurse works in a small clinic with two other nurses and a nurse practitioner. Recently the nurse has been staying at work longer than usual
His neighbor, a patient at the clinic, asks one of the other employees at the clinic how the nurse is coping since his wife left him. The nurse had not shared this information with his co-workers. The nurse may be coping with his loss with which of the following? a. Compensation b. Conversion c. Denial d. Dissociation
Your examination of a patient, who states that she is not able to see as clearly in her right eye as she has in the past, should include questions about associated manifestations such as
a. decreased moisture. c. stress and lack of sleep. b. eye pain and infection. d. sudden or gradual onset.
When caring for a client diagnosed with iron deficiency anemia, the nurse would instruct the client to ingest which food to ensure iron absorption?
A) Breads B) Cereals C) Pasta D) Lemonade