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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Imbalanced Nutrition: less than body requirements would be the nursing problem with the highest priority for an adolescent with anorexia nervosa. Anorexia nervosa is characterized by a severe restriction of food intake leading to a significantly low body weight, which can have serious physical and psychological consequences. Therefore, addressing the client's malnutrition and promoting adequate nutrition intake is crucial to prevent further complications. Disturbed Body Image, Interrupted Family Processes, and Noncompliance with treatment regimen are important nursing problems to address, but they are secondary to the client's malnutrition.

A. Maintain strict intake and output. B. Assess warmth of extremities. C. Keep head of bed raised 45 degrees. D. Monitor blood glucose level.

Correct Answer is A

Explanation

Septic shock is a life-threatening condition characterized by a severe infection that leads to systemic inflammation, organ dysfunction, and low blood pressure. Maintaining strict intake and output monitoring is essential to assess the client's fluid balance and response to interventions. It allows the nurse to closely monitor the client's urine output, which is a crucial indicator of renal perfusion and overall organ function.

Monitoring urine output helps the nurse assess the adequacy of tissue perfusion and the client's response to fluid resuscitation. A decrease in urine output can be an early sign of worsening organ dysfunction and a need for further interventions.

While assessing the warmth of extremities is important for evaluating peripheral perfusion, maintaining strict intake and output monitoring takes priority as it provides more comprehensive information about the client's overall fluid status.

Raising the head of the bed 45 degrees (semi-Fowler's position) can help optimize respiratory function and reduce the risk of aspiration, but it is not the most important intervention in this case.

Monitoring blood glucose levels is important, as hyperglycemia can be associated with sepsis. However, in the context of septic shock, maintaining strict intake and output monitoring takes precedence as it directly assesses the client's fluid balance and response to interventions.

It's crucial to note that the management of septic shock requires a multidisciplinary approach, and other interventions, such as administering appropriate antibiotics, initiating fluid resuscitation, and addressing the underlying source of infection, should also be implemented in a timely manner.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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