Complex Care Flashcards

A nurse is caring for a client with end-stage renal disease (ESRD) who is also receiving palliative care. The client develops severe hyperkalemia (K+ 6.8 mEq/L) with peaked T-waves on ECG. The physician orders sodium polystyrene sulfonate (Kayexalate). Which finding in this client's chart should prompt the nurse to question this order before administration?

Answer: The client has an advance directive requesting comfort-focused care only

An advance directive specifying comfort-focused or palliative-only care is the most critical finding to clarify before administering Kayexalate. This medication is a life-prolonging intervention that corrects a potentially fatal electrolyte imbalance — directly conflicting with a documented goal of care focused on comfort rather than disease management. The nurse must clarify goals of care with the team before proceeding. While constipation and opioid use are valid safety concerns with Kayexalate (risk of intestinal necrosis), they are secondary to confirming that the intervention aligns with the client's stated wishes.

A nurse is managing a client with septic shock who is receiving norepinephrine via central line at 0.15 mcg/kg/min. The client's MAP is 63 mmHg (target ≥65), urine output is 18 mL/hr over the last 2 hours, and serum lactate is 4.2 mmol/L (drawn 1 hour ago). The nurse receives orders to titrate norepinephrine up by 0.05 mcg/kg/min. Which assessment finding would most indicate that increasing the vasopressor is the appropriate next step?

Answer: Skin that is warm and flushed with bounding peripheral pulses

Warm, flushed skin with bounding peripheral pulses suggests distributive (vasodilatory) physiology, the hallmark of septic shock, where vasopressor support is indicated to restore adequate vascular tone and perfusion pressure. Increasing norepinephrine is most appropriate when hypotension is due to vasodilation. Cool, mottled skin with weak pulses suggests cardiogenic or hypovolemic etiology where vasopressors could worsen ischemia or where volume resuscitation is needed first. Tachycardia and low BP alone do not differentiate etiology. A high CVP could indicate fluid overload, where increasing a vasopressor without addressing cardiac output may not be beneficial.

A nurse is caring for a client with a stage 4 pressure injury to the sacrum with suspected osteomyelitis. The wound care order states: 'Irrigate with normal saline, pack loosely with calcium alginate rope, and cover with a foam dressing.' During assessment, the nurse observes the wound base has a significant amount of firmly adhered yellow slough. Which modification to the wound care approach should the nurse initiate or advocate for?

Answer: Switch the packing to a hydrogel-impregnated gauze to promote autolytic debridement of the slough

Hydrogel-impregnated gauze promotes autolytic debridement by donating moisture to the wound bed, rehydrating necrotic tissue and slough so the body's own enzymes can break it down — making it appropriate for firmly adherent slough in a stage 4 wound. Enzymatic debridement (collagenase) is also valid but typically requires a specific physician order and is not a nurse-initiated modification in most practice settings. High-pressure irrigation (Option B) risks damage to fragile wound tissue and is not recommended for stage 4 wounds with suspected osteomyelitis. Dry gauze packing with intentional adherence (wet-to-dry) is considered outdated and traumatic — it removes healthy granulation tissue along with necrotic tissue and is not evidence-based practice.

A nurse is preparing a client with chronic obstructive pulmonary disease (COPD) and right-sided heart failure (cor pulmonale) for discharge. The client is on home oxygen at 2 L/min via nasal cannula. During teaching, the client states, 'My neighbour told me that if I feel short of breath, I should just turn my oxygen up — the higher the better.' Which physiological explanation forms the most accurate basis for the nurse's response to this statement?

Answer: Clients with COPD rely on hypoxic drive and excessive supplemental oxygen may suppress their respiratory stimulus, causing hypoventilation

In clients with COPD who retain CO2 chronically, the central chemoreceptors become desensitized to elevated PaCO2. These clients may rely on peripheral chemoreceptors that respond to hypoxia (hypoxic drive) to stimulate breathing. Administering excessive supplemental oxygen can eliminate this hypoxic stimulus, causing hypoventilation and potentially fatal CO2 narcosis. This is why oxygen titration in COPD targets SpO2 of 88–92% rather than higher values. While oxygen toxicity and pulmonary vasoconstriction are real phenomena, they occur with prolonged high concentrations (typically FiO2 >60%) rather than modest nasal cannula flow increases, and rebound hypoxemia is not a well-established clinical concern in this context.

A nurse is caring for a client receiving total parenteral nutrition (TPN) via a central venous catheter. The TPN bag runs out unexpectedly and a new bag is not immediately available. The client has no peripheral IV access. Which action is the most appropriate immediate nursing intervention?

Answer: Hang 10% dextrose in water (D10W) through the central line at the same infusion rate as the TPN

When TPN is interrupted abruptly, the client is at high risk for rebound hypoglycemia because the pancreas has been producing insulin in response to the high dextrose content of TPN. Hanging D10W at the same rate temporarily maintains the dextrose infusion and prevents a sudden drop in blood glucose while the new TPN bag is prepared. Normal saline (Option C) provides no glucose and does not prevent hypoglycemia. Simply capping the line (Options A and D) without dextrose replacement is inappropriate because the hypoglycemia risk is immediate. D10W via a peripheral line would be preferred if access existed, but central administration of D10W is appropriate when no peripheral access is available.

A nurse is caring for a client who is 48 hours post-liver transplant. The client develops a temperature of 38.9°C, is increasingly jaundiced, and reports right upper quadrant pain. Serum bilirubin has risen from 42 μmol/L yesterday to 118 μmol/L today, and AST/ALT are markedly elevated. The immunosuppression regimen includes tacrolimus and mycophenolate mofetil. Which complication should the nurse prioritize reporting to the physician, and which early assessment finding would most support this suspicion?

Answer: Hepatic artery thrombosis; the nurse should assess for sudden cessation of bile output and confirm with Doppler ultrasound

Hepatic artery thrombosis (HAT) is the most feared early complication after liver transplantation and typically presents within the first 2 weeks post-operatively. Rapid onset of graft dysfunction with rising bilirubin, elevated LFTs, fever, and RUQ pain in the early post-transplant period is classic. HAT causes ischemia to the biliary system (which depends entirely on the hepatic artery for blood supply), leading to biliary necrosis and rapid graft failure. Sudden cessation or significant reduction in bile output from a T-tube is a key clinical sign, and urgent Doppler ultrasound is the immediate diagnostic step. Acute cellular rejection typically presents slightly later (day 5–10) and does not usually cause this rapid a rise in bilirubin. Tacrolimus toxicity and primary non-function have distinct presentations not matching this acute picture.