ATI: RN Adult Medical Surgical Kidney Disease

ATI: RN Adult Medical Surgical Kidney Disease Using the SBAR format, identify the info. Nurse Allyson received from report that will enable her to provide safe care to Mr. Jones. - correct answer S- Situation The ED admitted Mr. Jones at 4:30 AM for SOB and weakness. After treatment, he is transferring to the telemetry unit. B - Background 60 year old African-American male with a history of peripheral vascular disease, type 2 diabetes, chronic kidney disease, coronary artery disease, and atrial fibrillation. A provider recently discharged him from the facility after he treated Mr. Jones for atrial fibrillation and a type 2 diabetic ulcer of the right foot. Mr. Jones did not complete prescribed antibiotics after his discharge. He is non compliant in managing his diabetes. He smokes one pack of cigarettes a day and uses alcohol 3 to 5 times a week. A - Assessment Mr. Jones is awake, alert, and orientated x3. Current vitals are: BP 112/70, P: 158, R: 34, T: 99.1, and O2 sat 91% on 2 L via nasal cannula. ECG indicates atrial fibrillation; placed on telemetry. Chest x-ray: opacities greater in the right lung than left lung. Altered lab values include: sodium 128, potassium 5.1, BUN 44, creatinine 3.0, and glomerular filtration rate 25. His total bilirubin was 2.8, calcium 8.7, WBCs 16.1, hemoglobin 9.3, hematocrit 28.2, and blood glucose 71. We did a digoxin level, which was 0.6. He has a soiled dressing on his right foot and is a stage III ulcer. A #20 gauge IV catheter was inserted peripherally in his left forearm and a nurse gave him 1,000 mL of 0.9% sodium chloride. Intake: 1,000 mL Output: None. No family present. Nurse Allyson is preparing to perform a sterile dressing change to Mr. Jones's foot. After removing the exam gloves, performing hand hygiene, and gathering the needed supplies, what are the next steps Nurse Allyson should take for the dressing change? - correct answer 1. Apply clean gloves. 2. Remove dressing and place in moisture-proof bag. 3. Remove clean gloves. 4. Wash hands. 5. Apply sterile gloves. 6. Cover with sterile gauze. 7. Secure dressing. Nurse Allyson is preparing to call the provider about Mr. Jones's difficulty breathing. Which of the following orders should she recommend to the provider? - correct answer Furosemide (Lasix) 20 mg IV Mr. Jones's total urinary output is 50 mL. His total IV fluid intake since admission is 1550 mL. Which of the following is an appropriate nursing intervention at this time? - correct answer Obtain a bladder scan. Nurse Allyson is going to perform a bladder scan on Mr. Jones. Where should the transducer be placed on his abdomen? - correct answer Central abdomen, below the umbilicus. Nurse Allyson is planning care for a set of clients. Which of the following should be her priority action? - correct answer Check on the client who is reporting chest pain. The telemetry technician notified Nurse Allyson that Mr. Jones is having arrhythmia. Which of the following is the priority nursing intervention at this time? - correct answer Perform a focused assessment. Mr. Jones's heart monitor displays this rhythm strip. Which of the following is an appropriate nursing action? - correct answer Call the rapid response team. The provider gave Nurse Allyson new prescriptions to implement. Based on Mr. Jones's current symptoms, which of the following medications should she give him at this time? - correct answer Sodium polystyrene sulfonate (Kayexalate) 30 g PO once now Nurse Allyson is preparing to administer furosemide (Lasix) 40 mg IV. Available is furosemide 80 mg/5 mL. How many mL should she administer? - correct answer 2.5 mL Nurse Allyson and the provider are reviewing chronic kidney disease information with Mr. Jones. Which of the following statements made by Mr. Jones indicates he understands the information? - correct answer "I will need to eat a low-protein diet." Nurse Allyson is planning care for Mr. Jones, who has clinical manifestations of phlebitis. Which of the following is the priority action the nurse should take? - correct answer Remove the IV catheter. Nurse Allyson is planning care to Mr. Jone's central line. Which of the following should Nurse Allyson include in Mr. Jones's plan of care? - correct answer 1. Use a sterile technique to change the dressing. 2. Obtain consent before central line placement. 3. Change the catheter cap every 3 to 7 days. Nurse Allyson gave a report about Mr. Jones to the home health nurse. Which of the following data is in the appropriate section of the SBAR to facilitate appropriate and comprehensive communication? - correct answer R: Upon discharge, Mr. Jones is scheduled