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 A
Explanation
The Ortolani maneuver is a physical examination technique used to assess for developmental dysplasia of the hip (DDH) in newborns. During the maneuver, the nurse gently abducts the infant's hips and applies gentle pressure to detect any instability or "click" at the hip joint. A positive Ortolani maneuver, where a click or clunk is felt or heard, can indicate the presence of a hip dislocation or dysplasia.
Asymmetrical buttocks can be a sign of hip dysplasia in newborns, and a positive Ortolani maneuver is an important finding that suggests a potential hip joint problem. Reporting this assessment test result to the healthcare provider allows for further evaluation and appropriate management of the newborn's hip condition.
The Plumb line test, which assesses fetal position curvature, is not directly related to hip dysplasia and may not be significant in this context.
The Babinski test, which reveals fanning out of the toes, is used to assess the integrity of the infant's neurological system and is not specific to hip dysplasia.
The Moro test, also known as the startle response, is a reflex assessment used to evaluate the newborn's neurological and sensory function. While it is important to assess the overall neurological status of the newborn, the Moro test is not specific to hip dysplasia.
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