Questions 34

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Urinary Elimination NCLEX RN Questions Questions

Extract:

The following scenario applies to the next 1 items
The nurse is reviewing the medical record of a 55-year-old male client.
Item 1 of 1
History and Physical
0818: Client reports severe shortness of breath and swelling in his lower extremities. He reports a 3-day history of fatigue and decreased urine output. During the assessment, the client was alert and fully oriented. He has 2+ pitting pedal edema in the lower extremities. 2+ peripheral pulses in the upper extremities. Bibasilar crackles upon auscultation. Skin is warm, dry, and normal for ethnicity. Normoactive bowel sounds in all quadrants. Vital signs: T 98° F (36.7°C), P 89, RR 18, BP 164/95, pulse oximetry reading 96% on room air.

Laboratory Results
• Capillary blood glucose 121 mg/dL (6.72 mmol/L) [70-110 mg/dL (4-6 mmol/L)]
• Serum creatinine 2.5 mg/dL (221 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Serum BUN 36 mg/dL (12.9 mmol/L) ([10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum potassium: 5.2 mEq/L [3.5–5 mEq/L (3.5–5 mmol/L)]
• Urinalysis: Mild proteinuria, no hematuria

Intake and Output
24 hour fluid intake: 1560 mL
24 hour fluid output: 250 mL

Medical History
• hypertension
• hyperlipidemia
• coronary artery disease
• glaucoma
• diabetes mellitus (type two)
Current Medications
• carvedilol 6.25 mg p.o. daily
• multivitamin 1 tablet p.o. daily
• lisinopril 10 mg p.o. daily
• simvastatin 10 mg p.o. daily
• ergocalciferol 10000 units p.o. daily
• ethyl eicosapentaenoic acid 2 grams p.o. daily


Question 1 of 5

The nurse is reviewing the client's assessment data to prepare the client's care plan. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.

Action to Take

Prepare the client for peritoneal dialysis
Request a prescription for sodium chloride (normal saline) 500 mL bolus
Obtain an order to discontinue the lisinopril
Obtain a prescription for a continuous infusion of regular insulin
Request a prescription for a diuretic.

Potential Condition

Nephrotic syndrome
Hyperglycemia hyperosmolar syndrome
Acute kidney injury
Chronic kidney disease.

Parameter to Monitor

Peripheral pulses
Capillary blood glucose
Serum potassium
Temperature
Lung sounds.

Correct Answer: B: Acute kidney injury, A: Request a prescription for a diuretic, C: Obtain an order to discontinue the lisinopril, D: Serum potassium, E: Lung sounds.

Rationale: Elevated creatinine, BUN, and oliguria suggest AKI. Diuretics address fluid overload, discontinuing lisinopril prevents further renal stress, and monitoring potassium and lung sounds assesses progress.

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