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. Lifting the skin is a common technique used to assess skin turgor, which is the elasticity of the skin.By letting go, the nurse can observe how quickly the skin snaps back into place, indicating good or poor elasticity.
B. recording palpated temperature might be done during a focused assessment, but it wouldn't necessarily be the next step after lifting the skin.
C. measuring indentation depth might be relevant for assessing edema (swelling), but it's not the primary focus after lifting for turgor.
D. observing swelling could be assessed visually without lifting the skin, and while it's important, assessing elasticity comes first in this scenario.
Correct Answer is A
Explanation
A. Increased oxygen saturation indicates that the Venturi face mask is effectively delivering the specified concentration of oxygen. This is the primary goal of using a Venturi mask, which provides precise oxygen delivery to improve oxygen saturation levels.
B. Increased cough productivity is not a direct indicator of the effectiveness of a Venturi face mask. The mask's purpose is to deliver oxygen, not to alter cough patterns.
C. Decreased cough frequency is unrelated to the function of the Venturi face mask. The mask's effectiveness is measured by oxygen delivery rather than changes in cough frequency.
D. Decreased breath sounds are not a direct measure of the effectiveness of a Venturi face mask. Breath sounds could indicate other respiratory issues but do not specifically reflect the effectiveness of oxygen therapy.
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