A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?
No specific nursing action is required.
Collect a clean catch urine specimen.
Instruct the client to empty the bladder.
Obtain vital signs and breath sounds.
The Correct Answer is D
Acute kidney injury (AKI) can have significant impacts on the client's fluid and electrolyte balance. Mannitol, a diuretic, is commonly used to promote diuresis and increase urine
output in cases of AKI. However, it is essential to assess the client's hemodynamic status and overall condition before administering mannitol.
Obtaining vital signs (such as blood pressure, heart rate, respiratory rate, and temperature) helps evaluate the client's baseline status and monitor for any changes that may occur after administering mannitol. It is particularly important to assess blood pressure as mannitol can potentially cause hypotension as a side effect.
Assessing breath sounds is also crucial because pulmonary edema can occur as a complication of AKI. Mannitol administration may exacerbate this condition. Therefore, assessing breath sounds allows the nurse to monitor for signs of fluid overload, such as crackles or wheezes.
Collecting a clean catch urine specimen may be necessary for diagnostic purposes to assess kidney function and determine the presence or severity of acute kidney injury. However, obtaining vital signs and assessing breath sounds should be the first nursing intervention before administering any medication, including mannitol, to ensure the client's safety and monitor for any potential adverse effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.3"]
Explanation
1. Convert the infant's weight from pounds to kilograms. We can use the conversion factor 1 kg
= 2.2 lb. So, 22 lb x (1 kg / 2.2 lb) = 10 kg.
2. Calculate the total daily dose of amoxicillin for the infant. We can use the formula D = d x W, where D is the total daily dose, d is the dose per kg per day, and W is the weight in kg. So, D = 20 mg x 10 kg = 200 mg.
3. Calculate the single dose of amoxicillin for the infant. We can divide the total daily dose by the number of doses per day. Since the prescription is for every 8 hours, there are 3 doses per day. So, 200 mg / 3 = 66.67 mg.
4. Calculate the volume of amoxicillin suspension for the single dose. We can use the ratio of the concentration of the suspension, which is 250 mg per 5 mL. So, 66.67 mg x (5 mL / 250 mg) =
1.33 mL.
5. Round the volume to the nearest tenth= 1.3 mL
Correct Answer is ["B","C","D"]
Explanation
A) Incorrect- Standard precautions are used for all clients to prevent the spread of infections.
However, in the case of MRSA, contact precautions are needed due to the risk of direct transmission through physical contact.
B) Correct- Monitoring the white blood cell count is important to assess for signs of infection, as an elevated count might indicate an ongoing inflammatory response.
C) Correct- Foul-smelling drainage from an incision with suspected MRSA indicates a potential infection. Contact precautions are appropriate for MRSA, which include wearing gloves and gowns when entering the client's room to prevent the spread of the bacteria.
D) Correct- Sending wound drainage for culture and sensitivity helps identify the specific microorganisms causing the infection and guides appropriate antibiotic treatment.
E) Incorrect- A low-bacteria diet is not relevant to the situation. MRSA is caused by a bacterium, not by dietary factors. The focus should be on infection control measures and appropriate medical interventions.
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