A client with acute kidney injury (AKI) is admitted with an elevated heart rate and an elevated blood pressure. Which intervention should the practical nurse (PN) implement?
Monitor daily sodium intake.
Record usual eating patterns.
Document abdominal girth.
Measure and document urinary output.
The Correct Answer is D
A. Monitoring daily sodium intake is important for managing AKI, but it is not the immediate priority when addressing acute changes in heart rate and blood pressure.
B. Recording usual eating patterns is not relevant to the immediate concern of elevated heart rate and blood pressure in the context of AKI.
C. Documenting abdominal girth is relevant for assessing fluid status and potential complications like ascites, but it is not the first priority for addressing the acute symptoms of elevated heart rate and blood pressure.
D. Measuring and documenting urinary output is the most critical intervention because it provides essential information on kidney function and fluid balance, which directly impacts heart rate and blood pressure management in AKI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client who needs to ambulate for the first time since delivery requires the PN’s immediate attention to ensure safety and prevent complications such as orthostatic hypotension or falls.
B. A client prepared for discharge who has a question about teaching is important but does not take precedence over immediate safety concerns related to the client’s physical activity.
C. A tired client with twins who would like her babies returned to the nursery is important for the client’s well-being, but it is not as urgent as ensuring the safety of a postpartum client beginning to ambulate.
D. Removing indwelling urinary and intravenous catheters is important but not as urgent as ensuring the safety of a client ambulating for the first time after birth.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
- Clean the site using sterile gauze and sterile water.
- Indicated: The turban dressing should be changed using sterile techniques to prevent infection and ensure proper wound care.
- Place client in a private room.
- Not Indicated: The client is already on contact precautions for MRSA, so the private room is a general requirement and not a specific intervention for the dressing change.
- Avoid hand sanitizer after the procedure.
- Not Indicated: Hand sanitizer is typically used before and after procedures. For MRSA contact precautions, hand hygiene is critical, and proper hand washing or using hand sanitizer is recommended after the procedure.
- Place the soiled dressing in a red biohazard bag.
- Indicated: The soiled dressing is considered contaminated and should be disposed of in a red biohazard bag to prevent the spread of infection.
- Use sterile gloves to remove the old dressing.
- Indicated: Sterile gloves are required for removing and replacing the dressing to maintain a sterile field and prevent infection.
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