NUR 425 Exam 2

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121 Terms

1
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What does absolute neutrophil count measure?
The total number of neutrophils in the blood
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Which lab test is used to monitor the intrinsic pathway?
PTT (partial prothrombin time)
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Which lab test is used to monitor the extrinsic pathway?
PT (prothrombin time)
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aPTT (activated partial thromboplastin time)
30-40 seconds
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INR
1 or less
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PTT (partial prothrombin time)
60-70 seconds
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PT (prothrombin time)
10-13 seconds
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What drug does PT (prothrombin time) monitor?
Warfarin (Coumadin)
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What drug does PTT and aPTT monitor?
Heparin
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Red Blood Cell (RBC) Count
Females: 3.61 - 5.11 million/mm3 (4)
Males: 4.21 - 5.81 million/mm3 (5)
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Hematocrit
Females: 36% - 48% (39)
Males: 42% - 52% (45)
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Hemoglobin
Females: 11.7 - 15.5 g/dL (13)
Males: 14 - 17.3 g/dL (15)
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White Blood Cell (WBC) Count
4.50 - 11.1 103/mm3
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Absolute Neutrophil Count (ANC)
1.5 to 8.0 (1,500 to 8,000/mm3)
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Platelets
150,000 - 450,000/µL
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What does a WBC shift to the left mean?
-Indicates that more immature cells are present in the blood than normal
-Occurs with acute infection, inflammation, or some other significant physical stress
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What is anemia?
Occurs when there is a reduction in the oxygen-carrying capacity through either fewer RBCs or a reduction in hemoglobin
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What are symptoms of decreased hematocrit?
-Shortness of breath
-Tachypnea
-Tachycardia
-Pallor
-Fatigue
-Dizziness
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What are dietary sources of iron?
-Meat (especially red meat)
-Dark green leafy vegetables (spinach, broccoli, peas)
-Beets
-Dried beans
-Iron-fortified breakfast cereals and breads
-Cream of Wheat
-Ingesting citrus fruits such as oranges or grapefruits increases the vitamin C intake and may improve iron absorption
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What are clinical manifestations of iron-deficiency anemia?
-Fatigue
-Pallor
-Tachycardia
-Tachypnea
-Glossitis (smooth, shiny tongue)
-Koilonychia (spoon-shaped nails)
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How is iron-deficiency anemia diagnosed?
-A complete blood count (CBC) demonstrates decreased hemoglobin and hematocrit levels
-Serum ferritin levels less than or equal to 100 ug/L indicate IDA 100% of the time
-Additional diagnostic studies to confirm IDA include serum iron, total iron-binding capacity (TIBC), serum transferrin receptors, and mean corpuscular volume (MCV)
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What teaching do you need to provide to a client with iron-deficiency anemia?
-Dietary sources of iron
-Immediately report any signs of bleeding, increasing fatigue, or shortness of breath.
-Daily iron supplements must be taken as prescribed.
-Dangers of lead exposure
-Prenatal teaching about iron intake
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What are dietary sources of vitamin B12?
-Meat
-Seafood
-Eggs
-Dairy products
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What are clinical manifestations of vitamin B12 anemia?
-Fatigue
-Pallor
-Tachycardia
-Tachypnea
-Shortness of breath
-Dizziness
-Glossitis
-Neurological deficits:
•Symmetric paresthesia of feet and fingers
•Lhermitte's sign
•Confusion
•Depression
•Impaired taste
•Impaired balance
•Visual disturbances
•Tinnitus
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How is vitamin B12 anemia diagnosed?
-History and physical examination
-Vitamin B12 serum assay blood test
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What population is at increased risk of deficiency and may need to take a daily supplement of vitamin B12?
-Long-term vegans/vegetarians
-Those of low socioeconomic status
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What are clinical manifestations of folic acid deficiency?
-Fatigue
-Gray hair
-Mouth sores
-Swollen tongue
-Forgetfulness
-Depression
-Appetite loss
-Difficulty concentrating
-Birth defect
-Poor growth
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What are dietary sources of folic acid?
-Dark green vegetables
-Dried beans, legumes
-Fortified grains (breads, cereal)
-Nuts
-Bran
-Yeast
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What teaching do you need to provide to a client with folic acid deficiency?
-Dietary sources of folate/folic acid
-Immediately report any clinical manifestations of fatigue, shortness of breath, dizziness, and confusion.
-Prenatal teaching
-Need for supplementation
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What teaching do you need to provide to a client with sickle cell anemia?
-Pathophysiology of disease
-Infection prevention measures
-Avoid cold temperatures and wearing tight, restrictive clothing.
-Avoid high altitudes and depressurized airplanes.
-Avoid dehydration.
-Avoid overexertion.
-Maintain activities of daily life within prescribed limitations.
-Risk of more frequent sickle cell crises during pregnancy.
-Fetal complications
-Genetic counseling
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What are risk factors for sickle cell anemia?
-The sickle cell trait (SCT) is a genetic mutation that must be present in both parents in order for this form of the disease to manifest in offspring
-Parents who carry this gene have a one in four chance of producing a child with sickle cell anemia
-Precipitating factors include dehydration, cold temperatures, infection, and environments with low oxygen tension, such as depressurized airplane cabins and high mountains
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What are clinical manifestations of sickle cell anemia?
-Fatigue
-Pallor
-Shortness of breath
-Vasoocclusion of blood vessels resulting in pain and swelling
-Pain usually occurs in the joints, bones, chest, and abdomen
-Growth and developmental delays
-Hand-food syndrome
-Fatigue
-Pallor
-Shortness of breath
-Vasoocclusion of blood vessels resulting in pain and swelling
-Pain usually occurs in the joints, bones, chest, and abdomen
-Growth and developmental delays
-Hand-food syndrome
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What are priority nursing actions for sickle cell anemia?
-Administer oxygen.
-Provide aggressive hydration.
-Administer pain medication.
-Administer blood transfusions.
-Administer antipyretics.
-Provide supportive measures.
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What is the treatment for sickle cell anemia crisis?
Hydration
Oxygenation (comes first)
Pain relief
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What are clinical manifestations of aplastic anemia?
-Decreased RBCs: Fatigue, shortness of breath, tachycardia, pallor, dizziness, and headache
-Decreased WBCs: Increased susceptibility to infections, as well as frequent and prolonged infections
-Thrombocytopenia: Unexplained and increased incidence of bruising, nosebleeds, gum bleeding, and prolonged bleeding from cuts and other injuries
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What teaching do you need to provide to a client with aplastic anemia?
-Avoid exposure to potential infection (individuals with acute infection, crowded places).
-Report all temperature elevations.
-Avoid activities with the potential for trauma or injury.
-Clinical manifestations of anemia
-Nutritional intake
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What are clinical manifestations of thrombocytopenia?
-Easy bruising and petechiae
-Bleeding may occur from the nose, around the gums, or from the gastrointestinal tract
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What are priority nursing actions for thrombocytopenia?
-Implement bleeding precautions (RANDI)
-Minimize blood loss from lacerations or venipuncture.
-Avoid intramuscular injections.
-Avoid rectal temperatures, enemas, suppositories, and douches.
-Provide a safe environment.
-Use minimal inflation when assessing blood pressure.
-Minimize blood draws.
-Implement bleeding precautions (RANDI)
-Minimize blood loss from lacerations or venipuncture.
-Avoid intramuscular injections.
-Avoid rectal temperatures, enemas, suppositories, and douches.
-Provide a safe environment.
-Use minimal inflation when assessing blood pressure.
-Minimize blood draws.
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What are safety interventions for thrombocytopenia?
Bleeding precautions
Bleeding precautions
40
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What are risk factors for leukemia?
-Genetic anomalies
-Down's syndrome
-Exposure to radiation or benzene
-Chemotherapeutic agents and/or radiation therapy
-Smoking
-White males over the age of 60
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What are clinical manifestations of leukemia?
Anemia: Decreased hemoglobin, fatigue, pallor, weakness, and shortness of breath, as well as bruising, petechiae nosebleeds, and bleeding gums from the decreased number of platelets
Neutropenia: Risk for infection, low-grade fevers
Thrombocytopenia: Risk for bleeding
Anemia: Decreased hemoglobin, fatigue, pallor, weakness, and shortness of breath, as well as bruising, petechiae nosebleeds, and bleeding gums from the decreased number of platelets
Neutropenia: Risk for infection, low-grade fevers
Thrombocytopenia: Risk for bleeding
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What are diagnostic tests for leukemia?
-CBC
-History and physical examination
-Bone marrow biopsy
-Genetic testing
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What are priority nursing actions for leukemia?
-Administer chemotherapy as prescribed.
-Institute neutropenic precautions.
-Prophylactic use of antibiotics, antivirals, and antifungals as ordered
-Administer IV antibiotics.
-Symptom management (nausea/vomiting/diarrhea, ulcerations of the mouth)
-Administer ordered blood products.
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What teaching do you need to provide to a client with leukemia?
-Neutropenic precautions
-Clinical manifestations of anemia
-Manifestations of thrombocytopenia
-Bleeding precautions
-Diagnosis of leukemia
-Adverse reactions of chemotherapy or radiation
-Possibility of sterility
-Neutropenic precautions
-Clinical manifestations of anemia
-Manifestations of thrombocytopenia
-Bleeding precautions
-Diagnosis of leukemia
-Adverse reactions of chemotherapy or radiation
-Possibility of sterility
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What are clinical manifestations for malignant lymphoma?
-Painless swelling of the lymph nodes in the neck, underarm, and groin
-Low-grade fevers for no apparent reason
-Drenching night sweats
-Unexplained weight loss of more than 10% in less than 6 months
-Fatigue
(known as the "B symptoms")
-Generalized pruritus, or itching, with pronounced excoriation from scratching is present in a large percentage of patients presenting with Hodgkin's disease (HD)
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What teaching do you need to provide to a client with malignant lymphoma?
-Disease process
-Risk of infection
-Maintaining treatment schedules
-Encourage frequent rest periods.
-Dietary intake
-Clinical manifestations of potential complications
-Possibility of sterility
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What are clinical manifestations of multiple myeloma?
-Fatigue
-Weakness
-Bone pain
-Recurrent infections
-Weight loss
-Paresthesia
-Fatigue
-Weakness
-Bone pain
-Recurrent infections
-Weight loss
-Paresthesia
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What does the nursing assessment include for multiple myeloma?
-Vital signs
-Fatigue, pallor, and shortness of breath
-Pain
-Paresthesias
-Intake and output
-Serum and urine calcium
-Serum blood urea nitrogen (BUN) and creatinine
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What teaching do you need to provide to a client with multiple myeloma?
-Immediately report any clinical manifestations of fatigue, shortness of breath, dizziness, or confusion.
-Report any sudden onset of severe pain or new location, especially of back pain, which could indicate a pathological fracture.
-Report changes in sensation, increased numbness and tingling, or changes in motor function.
-Instruct in the use of nonpharmacological pain management methods, such as music, relaxation, deep breathing, imagery, distraction, and progressive muscle relaxation.
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What effect does renal insufficiency have on RBC count?
Decreases RBC count
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What are examples of potential nephrotoxic substances?
-Antibiotics
-Analgesics: NSAIDS
-Other medications: ACE inhibitors, benzodiazepines, contrast media, diuretics
-Substances: Cocaine, gold, heroin, lead, mercury
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What is anuria?
-Less than 100-mL urine output/24 hr
-Clinical significance of abnormal finding: End-stage renal disease, acute renal failure, urinary tract obstruction
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What is dysuria?
-Difficulty or pain with urination
-Clinical significance of abnormal finding: Urinary tract infection, cystitis (bladder infection)
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What is enuresis?
-Involuntary urination at night
-Clinical significance of abnormal finding: Lower urinary tract disorder
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What is frequency?
-Increase in incidence of voiding, usually urinating only small amounts with each void
-Clinical significance of abnormal finding: Bladder inflammation, excessive fluid intake, urinary retention
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What is hematuria?
-Presence of blood in the urine
-Clinical significance of abnormal finding: Cystitis or other inflammation in the urinary tract, calculi, cancers of the urinary tract, renal disease, bleeding disorders, medications such as anticoagulants
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What is hesitancy?
-Difficulty starting the flow of urine
-Clinical significance of abnormal finding: Urethral obstruction, enlargement of the prostate gland (benign or malignant)
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What is incontinence?
-Inability to voluntarily control micturition
-Clinical significance of abnormal finding: Bladder infections, trauma to the external sphincter, neurogenic bladder, trauma to the nerve innervating the urinary tract structures
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What is nocturia?
-Frequent urination at night
-Clinical significance of abnormal finding: Heart failure, renal disease, bladder obstruction, consumption of excessive fluids late at night
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What is oliguria?
-Decreased urine output; less than 400-mL urine output/24 hr
-Clinical significance of abnormal finding: Shock, end-stage renal disease, acute kidney injury, severe dehydration, blood transfusion reaction
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What is polyuria?
-Increased urine output; greater than 2,000-mL urine output/24 hr
-Clinical significance of abnormal finding: Excessive fluid intake, diabetes insipidus, diabetes mellitus, diuretic medications, diuresis phase of chronic renal failure
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What is renal colic?
-Pain radiating to the perineal or groin area
-Clinical significance of abnormal finding: Ureter spasm during passage of calculi, ureter obstruction
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What is retention?
-Inability to completely empty the bladder of urine
-Clinical significance of abnormal finding: Normal finding briefly after childbirth, pelvic surgery, and removal of indwelling catheter
Prolonged/abnormal related to neurogenic bladder, obstruction or stricture of the urethra
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What is urgency?
-Sudden onset of the urge to void immediately
-Clinical significance of abnormal finding: Medications, pelvic organ prolapse, cystitis, UTI
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Serum Creatinine
0.5 - 1.2 mg/dL
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Blood Urea Nitrogen (BUN)
8 - 21 mg/dL
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BUN/Creatinine Ratio
10:1 to 20:1
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Uric Acid
3.5 - 8 mg/dL
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Bicarbonate
22 - 26 mEq/L
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Sodium
135 - 145 mEq/L
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Potassium
3.5 - 5.0 mEq/L
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Phosphorus
2.5 - 4.5 mEq/L
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Calcium
8.2 - 10.2 mEq/dL
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Urine Specific Gravity
1.005 - 1.030
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Glomerular Filtration Rate (eGFR)
85 - 110 is ideal
> 60 normal
< 15 can indicate possible kidney failure
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What are clinical manifestations of hyperkalemia?
Cardiac abnormalities
-Life-threatening dysrhythmias such as ventricular fibrillation, ventricular tachycardia, or asystole
-The initial indication on an ECG is peaked T waves
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What does an increased urine specific gravity indicate?
Dehydration
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What is a nursing intervention for increased urine specific gravity?
Increase fluids for hydration
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What are clinical manifestations of PKD?
-Hypertension
-Hematuria
-Flank pain
-Headaches
-Pain in the abdominal area
-Manifestations of UTI
-Bilaterally enlarged kidneys
-Increased abdominal girth
-Costovertebral angle tenderness
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What are priority nursing interventions for PKD?
-Diet modification consistent with impaired renal function, specifically low potassium, phosphorus, protein, and sodium
-Fluid restriction
-Administer antihypertensive agents as ordered.
-Administer antibiotics as ordered.
-Administer pain medication as ordered.
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How do you use therapeutic communication with a client who has PKD?
-Provide psychosocial support to client and family -Teach the client and family about prescribed treatments
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What are the plan of care goals for a client with PKD?
-Prevent complications
-Medication compliance (antihypertensives, antibiotics, etc)
-Diet modification
-Vital signs within reasonable limits
-Absence of infection
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What kind of diet should a client with PKD follow?
-Diet modification consistent with impaired renal function, specifically low potassium, phosphorus, protein, and sodium
-Diet modification is essential to prevent severe complications from eating foods high in protein, potassium, and phosphorus that the kidneys cannot excrete adequately
-Excess sodium intake can cause fluid retention
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What teaching do you need to provide to a client with PKD?
-Immediately report clinical manifestations of infection.
-Follow prescribed dietary restrictions.
-Follow prescribed antihypertensive therapy.
-Follow prescribed antibiotics for diagnosed UTIs.
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What are risk factors for pyelonephritis?
-Multiple pre-existing UTIs, treated or untreated which may be caused by:
+Vesicoureteral reflux
+Obstructions such as benign prostatic hypertrophy (BPH), a stricture, or a urinary stone
+A long-term indwelling urinary catheter
+Pregnancy
+Sexual activity in women
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What are clinical manifestations of pyelonephritis?
-Signs of infection (fever, chills, nausea, and vomiting)
-Back or flank pain
-CVA tenderness and enlarged kidneys
-Frequent and painful urination, and hematuria
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What are clinical manifestations of pyelonephritis in the elderly?
-Fever
-Acute dysuria
-New or worse urinary urgency or incontinence
-Gross hematuria
-Suprapubic or costovertebral pain
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What are the plan of care goals for a client with pyelonephritis?
-Complications such as damage to renal structures, scarring, and chronic pyelonephritis can be avoided with proper treatment, follow-up care, and prevention
-No symptoms associated with pyelonephritis, such as burning or pain on urination, urinary frequency, hesitancy, urgency, nocturia, and hematuria
-Self-care efforts and compliance with treatment are evident from improvements in symptoms and reductions in recurrent infections
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What are nursing actions for pyelopnephritis?
-Administer prescribed antibiotics as ordered.
-Administer prescribed pain medications.
-Provide adequate hydration, PO or IV as ordered.
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What teaching do you need to provide to a client with pyelonephritis?
-Explain the disease condition to the patient and family.
-Instruct the patient and family on how to avoid UTIs.
-Take prescribed medications as ordered.
-Instruct the patient and family on the importance of rest.
-Explain the disease condition to the patient and family.
-Instruct the patient and family on how to avoid UTIs.
-Take prescribed medications as ordered.
-Instruct the patient and family on the importance of rest.
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What are complications of pyelonephritis?
-Scarring, chronic kidney disease (CKD), or permanent damage
-Multisystem organ failure as a result of septic shock
-Changes in mental status, fever, tachycardia, tachypnea, hypotension, oliguria, and leukopenia are the early signs of urosepsis
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What are risk factors for acute glomerulonephritis?
-Infections such as recent strep
-Immune diseases such as lupus, vasculitis, hypertension, and diabetes
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What are clinical manifestations of acute glomerulonephritis?
-Proteinuria
-Hematuria
-Presence of WBCs and casts in urine
-Edema
-Decreased urine output (oliguria)
-Hypertension
-Elevated BUN and creatinine
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What teaching do you need to provide to a client with acute glomerulonephritis?
-Overview of the disease process
-Prescribed medications
-Dietary restrictions
-Avoid infections
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What is considered the typical treatment for renal cancer?
Radical nephrectomy
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What is a radical nephrectomy?
Involves removal of the affected kidney, adrenal gland, and surrounding tissues, such as the fascia, part of the ureter, and the draining lymph nodes
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What is the survival rate after undergoing a radical nephrectomy?
With early detection, renal cancer has shown a 60% to 70% 5-year survival
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What teaching do you need to provide to a client who is undergoing a radical nephrectomy?
-Avoid lifting >5 lbs
-Do not engage in strenuous activity
-Understand measures to protect function of remaining kidney (control BP, drink adequate fluids, limit NSAID use, stop smoking)
-PO hydration
-Cough and deep breathe
-Keep dressing clean
-Take medications as prescribed
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What teaching do you need to provide to a client with renal cancer?
-Teach the patient and family about the condition and any procedures or diagnostic tests.
-Teach the patient and family regarding medications.
-Provide appropriate resources for counseling regarding the disease process, tests and procedures, changes in body image, and financial concerns
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What are postoperative actions following a radical nephrectomy?
-Administer pain medication as ordered.
-Administer IV hydration as ordered/encourage PO hydration as ordered.
-Encourage respiratory exercises.
-Appropriate care of catheters, stents, nephrostomy tubes, or drains
-Perform wound care as ordered.