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 C
Explanation
Choice A rationale: Initiating the urine collection without reporting the low serum creatinine is inappropriate. A value of 0.3 mg/dL is below the reference range and may indicate significant muscle wasting or severe malnutrition.
Choice B rationale: Evaluating the BUN level provides information about hydration and renal perfusion, but it does not address the immediate clinical significance of an abnormally low creatinine level in an older adult client.
Choice C rationale: The nurse must notify the provider because a creatinine level of 0.3 mg/dL is abnormally low. In older adults, this often reflects low muscle mass, which significantly impacts how drug dosages are calculated.
Choice D rationale: Assessing for hypokalemia is not directly indicated by a low creatinine level. While electrolyte monitoring is important in drug toxicity, it is not the priority action linked to this specific lab finding.
Correct Answer is D
Explanation
The correct answer is choice d. Explain to the parents that anger is a common response to grief.
Choice A rationale:
Referring the parents to the chaplain for grief counseling can be beneficial, but it may not address the immediate emotional outburst and the need for understanding their feelings.
Choice B rationale:
Telling the parents that blaming each other will not change the situation might be true, but it can come across as dismissive and may not provide the emotional support they need at that moment.
Choice C rationale:
Assuring the parents that a terminal diagnosis is inevitable does not address their current emotional state and may seem insensitive to their grief and anger.
Choice D rationale:
Explaining to the parents that anger is a common response to grief helps them understand their emotions and provides immediate emotional support, making it the best intervention in this situation.
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