Page 1892 - Saunders Comprehensive Review For NCLEX-RN

Priority Concepts: Elimination; Inflammation
Reference: Ignatavicius, Workman, Rebar (2018), pp. 1474, 1476.

651. Answer: 1, 2, 3, 4

Rationale: If outflow drainage is inadequate, the nurse attempts to stimulate
outflow by changing the client’s position. Turning the client to the side or making
sure that the client is in good body alignment may assist with outflow drainage. The
drainage bag needs to be lower than the client’s abdomen to enhance gravity
drainage. The connecting tubing and peritoneal dialysis system are also checked for
kinks or twisting, and the clamps on the system are checked to ensure that they are
open. There is no reason to contact the PHCP. Increasing the flow rate should not be
done and also is not associated with the amount of outflow solution.
Test-Taking Strategy: Focus on the subject, outflow is less than inflow, and use
the principles related to gravity flow and preventing obstruction to flow to answer
this question. This will assist in determining the correct interventions.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Renal and Urinary
Health Problem: Adult Health: Renal and Urinary: Chronic kidney disease
Priority Concepts: Clinical Judgment; Elimination
Reference: Ignatavicius, Workman, Rebar (2018), p. 1420.

652. Answer: 4

Rationale: Steal syndrome results from vascular insufficiency after creation of a
fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The
client also complains of pain distal to the fistula, caused by tissue ischemia. Warmth
and redness probably would characterize a problem with infection. Ecchymosis and
a bruit are normal findings for a fistula.
Test-Taking Strategy: Focus on the subject, arterial steal syndrome. Eliminate
signs associated with infection or normal fistula findings. Recalling that steal
syndrome results from vascular insufficiency after creation of a fistula will direct
you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Renal and Urinary
Health Problem: Adult Health: Renal and Urinary: Chronic kidney disease
Priority Concepts: Clinical Judgment; Perfusion
Reference: Ignatavicius, Workman, Rebar (2018), p. 1415.

653. Answer: 1

Rationale: The creatinine level is the most specific laboratory test to determine
renal function. The creatinine level increases when at least 50% of renal function is

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