A client with end stage renal disease presents to the emergency department with severe fatigue, palpitations, and muscle weakness.
The electrocardiogram reveals peaked T waves and a widened QRS complex. Which treatment should the nurse anticipate?

Administer a loop diuretic.

Administer furosemide.

Initiate hemodialysis.

Increase fluid intake.

Answer and Explanation

The Correct Answer is C

Managing electrolyte imbalances in end stage renal disease requires understanding renal excretion failures. The presence of cardiac rhythm changes indicates a life threatening emergency. Immediate intervention is necessary to remove toxins and excess ions that the kidneys cannot process.

Choice A rationale

Loop diuretics are ineffective for clients with end stage renal disease because the nephrons are no longer functional. These medications cannot induce diuresis or lower serum potassium levels when the kidneys have reached the point of failure.

Choice B rationale

Similar to other loop diuretics, furosemide relies on renal blood flow and functional kidney tissue to promote fluid and electrolyte excretion. In end stage failure, this medication will not resolve the cardiac symptoms or hyperkalemia.

Choice C rationale

This is the definitive treatment for life threatening hyperkalemia in renal failure. Dialysis rapidly removes excess potassium and metabolic waste from the blood. It corrects the electrical instability in the heart caused by the high potassium levels.

Choice D rationale

Increasing fluid intake is contraindicated in end stage renal disease due to the risk of fluid volume overload. This would exacerbate the client's condition, potentially leading to pulmonary edema, hypertension, and worsening of the cardiac strain.

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Correct Answer is D

Explanation

Accurate estimation of burn size is critical for fluid resuscitation and metabolic support. This scenario requires applying the Rule of Nines, which assigns specific percentages to body regions to quantify the total body surface area affected by thermal injury.

Step 1 is 18 percent for the entire back area.

Step 2 is 18 percent for the anterior and posterior surfaces of the right leg.

Step 3 is 18 percent for the anterior and posterior surfaces of the left leg.

Step 4 is 9 percent for the left arm.

Step 5 is 18 + 18 + 18 + 9 = 63 percent total body surface area.

A. Obtain CVP reading. B. Provide oral care at least q hr. C. Obtain hourly capillary blood glucose measurements per agency policy. D. Titrate norepinephrine infusion rates based on patient's systolic blood pressure readings. E. Obtain hourly vital signs, including urinary output. F. Measure and document I and O.

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

Explanation

Delegation requires understanding the scope of practice for unlicensed assistive personnel versus licensed nurses. Tasks involving clinical judgment, titration of medications, or invasive monitoring must be reserved for the registered nurse, while routine, non-invasive tasks can be safely delegated.

Choice A rationale

Central venous pressure monitoring involves an invasive line and requires clinical interpretation of waveforms and readings. This task is beyond the scope of unlicensed personnel and must be performed by a nurse to ensure accuracy and safety.

Choice B rationale

Oral care is a routine hygiene task that falls within the scope of practice for unlicensed assistive personnel. Regular oral care is essential for preventing ventilator-associated pneumonia and maintaining mucosal integrity in critically ill septic patients.

Choice C rationale

While some glucose monitoring can be delegated, hourly measurements in a septic patient typically require clinical titration of insulin or close monitoring of metabolic instability. Agency policies often restrict high-frequency or critical-care monitoring to licensed staff.

Choice D rationale

Titration of vasoactive medications like norepinephrine requires advanced clinical judgment and assessment of hemodynamics. This is a complex nursing intervention that can never be delegated to unlicensed staff due to the high risk of hemodynamic instability.

Choice E rationale

Assessing vital signs in a hemodynamically unstable septic patient involves clinical evaluation. Furthermore, measuring urine output via a catheter in an intensive care setting is often combined with assessing renal perfusion, requiring professional nursing oversight.

Choice F rationale

Measuring and documenting intake and output is a standard technical task delegated to unlicensed personnel. While the nurse must interpret the clinical significance of the balance, the manual collection and recording of data are appropriate delegated duties.

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A client with end stage renal disease presents to the emergency department with severe fatigue, palpitations, and muscle weakness. The electrocardiogram reveals peaked T waves and a widened QRS complex. Which treatment should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has burns to the entire back, anterior and posterior surfaces of both legs, and the left arm. Using the Rule of Nines, what percentage of total body surface area is burned?

Correct Answer is D

Explanation

The intensive care nurse is caring for a client with sepsis. Which interventions can the nurse delegate to the unlicensed assistive personnel? Select All that Apply.

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

Explanation

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The nurse in the burn unit provides discharge instructions for a client who received a skin graft due to deep partial-thickness burns from a work accident at a chemical plant. Which instruction should the nurse prioritize?

The nurse assesses the hand of a client who has a thermal burn. Which actions should the nurse include in the plan of care? Select all that apply.

A client with end stage renal disease presents to the emergency department with severe fatigue, palpitations, and muscle weakness.
The electrocardiogram reveals peaked T waves and a widened QRS complex. Which treatment should the nurse anticipate?