Page 1893 - Saunders Comprehensive Review For NCLEX-RN

lost. A decreased hemoglobin level and red blood cell count are associated with
anemia or blood loss and not specifically with decreased renal function. Increased
white blood cells in the urine are noted with urinary tract infection.
Test-Taking Strategy: Note the strategic words, most likely. Recalling the
relationship between the creatinine level and renal function 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: Cellular Regulation; Elimination
Reference: Ignatavicius, Workman, Rebar (2018), pp. 1331-1332.

654. Answer: 3

Rationale: A temperature of 101.2° F (38.5° C) is significantly elevated and may
indicate infection. The nurse should notify the primary health care provider (PHCP).
Dialysis clients cannot have fluid intake encouraged. Vital signs and the shunt site
should be monitored, but the PHCP should be notified first.
Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the data
in the question. Note the temperature elevation. This warrants notification of the
PHCP, who may prescribe diagnostic tests or medications.
Level of Cognitive Ability: Applying
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), pp. 1415-1416.

655. Answer: 4

Rationale: Disequilibrium syndrome may be caused by rapid removal of solutes
from the body during hemodialysis. These changes can cause cerebral edema that
leads to increased intracranial pressure. The client is exhibiting early signs and
symptoms of disequilibrium syndrome, and appropriate treatments with
anticonvulsive medications and barbiturates may be necessary to prevent a life-
threatening situation. The PHCP must be notified. Monitoring the client, elevating
the head of the bed, and assessing the fistula site are correct actions, but the priority
action is to notify the PHCP.
Test-Taking Strategy: Note the strategic word, priority, and focus on the client’s
signs and symptoms. Determine if an abnormality exists. Recalling the serious
complications associated with hemodialysis such as disequilibrium syndrome will
direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity

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