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 B
Explanation
The correct answer is Choice B.
Choice A rationale: Ice application induces vasoconstriction, which reduces swelling but does not evert inverted nipples. This action does not address the primary issue of nipple inversion preventing adequate latch.
Choice B rationale: Breast pump use creates negative pressure, drawing out the nipple. This eversion facilitates latching by providing a more prominent nipple for the infant's oral cavity to grasp effectively.
Choice C rationale: Supplemental formula feedings provide nutrition, but do not resolve the latching difficulty caused by inverted nipples. This can interfere with the establishment of the mother's milk supply.
Choice D rationale: Breast shields can aid latching, but they are most effective when used in conjunction with nipple eversion techniques. They do not directly address the underlying problem of inverted nipples.
Correct Answer is B
Explanation
A) Incorrect- Anal abscesses and fistulas are more commonly associated with Crohn's disease than with ulcerative colitis. Crohn's disease can involve the entire thickness of the bowel wall and create tunnels or connections (fistulas) between different parts of the gastrointestinal tract.
B) Correct- Rectal bleeding is a common symptom of ulcerative colitis, as the inflamed tissue can bleed easily.
C) Incorrect- Constipation is not a common characteristic of Crohn's disease. In fact, both ulcerative colitis and Crohn's disease can lead to a range of bowel habits, including diarrhea and constipation, depending on the extent and location of inflammation.
D) Incorrect- Both ulcerative colitis and Crohn's disease are inflammatory bowel diseases (IBD) that involve chronic inflammation of the gastrointestinal tract. Ulcerative colitis primarily affects the colon and rectum, causing continuous areas of inflammation and ulceration. Crohn's disease can affect any part of the gastrointestinal tract, from the mouth to the anus. It often involves patches of inflammation with healthy tissue in between, and it can affect different layers of the bowel wall.
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