A client is in the oliguric phase of acute kidney injury (AKI) which was caused by massive tissue trauma. The nurse notes peaked T-waves and a widened QRS complex on the cardiac monitor. What is the first action the nurse should take?

Check the client's most recent potassium level

Administer a bolus of 1,000 mL of normal saline

Administer potassium chloride intravenously (IV)

Administer sodium polystyrene sulfonate (Kayexalate)

Answer and Explanation

The Correct Answer is A

A.   Peaked T-waves and a widened QRS complex on an ECG are often signs of hyperkalemia, which is an elevated potassium level in the blood. This can be a serious complication of acute kidney injury (AKI), especially in the oliguric phase when the kidneys are unable to effectively excrete potassium.A
B.   While fluid management is important in AKI, administering a bolus of normal saline is not the first priority in the presence of suspected hyperkalemia. The primary concern is to address the electrolyte imbalance.

C.   Administering potassium chloride would worsen hyperkalemia and should be avoided.
D.   Kayexalate is a medication used to treat hyperkalemia by exchanging sodium ions for potassium ions in the gastrointestinal tract. However, checking the potassium level is the first step in confirming the diagnosis and determining the appropriate treatment.

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Correct Answer is D

Explanation

A. Peptic ulcers are sores that develop on the lining of the stomach, small intestine, or esophagus due to the erosion caused by stomach acid. A Mallory-Weiss tear is not related to peptic ulcers. Instead, it results from a different type of injury related to forceful vomiting or retching.
B. Chewable aspirin is not a treatment for Mallory-Weiss tears. In fact, aspirin can exacerbate bleeding and is typically avoided in situations where gastrointestinal bleeding is present. Mallory-Weiss tears are generally managed by supportive measures and sometimes endoscopic interventions, not with aspirin.
C. A Mallory-Weiss tear specifically affects the mucosal lining at the junction of the esophagus and the stomach, not the duodenum. The duodenum is part of the small intestine, and tears or bleeding here are not characteristic of Mallory-Weiss syndrome.

D. A Mallory-Weiss tear is a tear or laceration in the mucosal lining at the gastroesophageal junction (where the esophagus meets the stomach). It is typically caused by severe vomiting or retching, which can lead to the tear and subsequent upper gastrointestinal bleeding.

A. Place client on total bedrest and avoid use of affected joints B. Provide warm compresses to affected joints C. Place several pillows under the head to keep the neck in a flexed position D. Place the client on continuous cardiac monitoring E. Administer methylprednisolone as ordered

Correct Answer is ["B","E"]

Explanation

A. Total bedrest is generally not recommended. It is important to balance rest with gentle movement to maintain joint function and prevent stiffness. Instead of complete bedrest, promoting periods of rest

while allowing for limited activity as tolerated is more appropriate. Avoiding use of affected joints may be beneficial during acute inflammation but complete immobilization can lead to muscle atrophy and joint stiffness.
B. Applying warm compresses to affected joints can help relieve stiffness and pain associated with RA. Warmth can improve blood flow and reduce muscle tension around the joints. This intervention is typically beneficial during periods of stiffness and can help increase comfort. However, cold compresses may also be used during acute inflammation to reduce swelling.
C. Placing pillows to keep the neck in a flexed position is not advisable for RA patients. It can cause discomfort and potentially worsen joint and muscle issues. Proper positioning should support natural body alignment, and patients should be encouraged to maintain a neutral neck position to avoid additional strain.
D. Continuous cardiac monitoring is not a routine intervention for RA exacerbations unless there is an indication of cardiac involvement or complications. RA itself does not typically require continuous cardiac monitoring.
E. Methylprednisolone is a corticosteroid used to reduce inflammation and manage RA symptoms during flares. Administering it as ordered is an appropriate intervention to control inflammation and alleviate symptoms.

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A client is in the oliguric phase of acute kidney injury (AKI) which was caused by massive tissue trauma. The nurse notes peaked T-waves and a widened QRS complex on the cardiac monitor. What is the first action the nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient is admitted with upper GI bleeding following an episode of forceful vomiting due to excessive alcohol intake. The nurse suspects a Mallory-Weiss tear. Which of the following is true of a Mallory-Weiss tear?

Correct Answer is D

Explanation

A client is admitted to the hospital during an exacerbation of rheumatoid arthritis (RA). Which of the following nursing interventions are appropriate for a client experiencing an RA flare? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

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