A nurse in a provider's office is caring for a client who has a medical history of rheumatoid arthritis and psoriasis, and a family history of heart disease and arthritis. The client has a 60-year smoking history and denies alcohol or other substance use. They are positive for Helicobacter pylori and are on medication for peptic ulcer disease (PUD). Which three findings from the client's medical record increase their risk for peptic ulcer disease?

Choice A rationale
In the case of hyperkalemia, which can cause fatal cardiac arrhythmias, the most immediate nursing action is to place the patient on a cardiac monitor. This allows for continuous monitoring of the heart's rhythm and immediate detection of any life-threatening changes, which is crucial for timely intervention.

Choice B rationale
Inserting a urinary retention catheter may be necessary for managing oliguria, but it is not the most urgent action when compared to the potential cardiac risks associated with hyperkalemia.

Choice C rationale
Administering spironolactone, a potassium-sparing diuretic, could be part of the treatment for hyperkalemia, but it is not the first action to take. Spironolactone works more slowly and does not address the immediate risk of cardiac arrhythmias.

Choice D rationale
Epoetin alfa (Epogen) is used to treat anemia, particularly in chronic kidney disease, to increase red blood cell production. However, it does not have an immediate effect and is not the priority in the presence of hyperkalemia and potential cardiac complications.

Choice A rationale
Removing catheters as soon as they are no longer necessary can significantly reduce the risk of catheter-associated urinary tract infections (CAUTIs)¹.

Choice B rationale

While it is important for clients to urinate when they feel the urge, this practice alone is not specifically targeted at reducing the rate of urinary tract infections.

Choice C rationale

Teaching proper perineal care, including wiping from front to back, can help prevent the spread of bacteria to the urethra and reduce the risk of UTIs¹.

Choice D rationale

Continuing prescribed antibiotics until the full course is completed, even if symptoms improve, is crucial to ensure all bacteria are eliminated and to prevent antibiotic resistance³.

Choice E rationale

Adequate fluid intake helps flush bacteria from the urinary tract, which can decrease the incidence of UTIs¹.