A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?
Insert a urinary catheter.
Prepare the client for an intravenous pyelogram.
Administer IV fluids to the client.
Initiate beta blocker therapy.
The Correct Answer is C
A. Insert a urinary catheter: While a urinary catheter may be necessary for monitoring urine output, it does not directly prevent acute kidney failure. Maintaining adequate perfusion and hydration is the primary concern in preventing kidney injury.
B. Prepare the client for an intravenous pyelogram: An intravenous pyelogram (IVP) involves contrast dye, which can be nephrotoxic and potentially worsen kidney function. It is not appropriate in a client at risk for acute kidney injury.
C. Administer IV fluids to the client: Fluid resuscitation helps maintain adequate renal perfusion and prevents hypovolemia-induced acute kidney failure. Clients with significant blood loss are at high risk for prerenal kidney injury due to decreased perfusion.
D. Initiate beta blocker therapy: Beta blockers are used for cardiovascular conditions but do not prevent acute kidney failure. In this situation, maintaining blood volume and renal perfusion is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Constipation: Radiation therapy to the neck does not typically affect the gastrointestinal system directly. Constipation is more commonly associated with opioid pain management or radiation targeting the abdominal or pelvic region rather than the head and neck area.
B. Peripheral neuropathy: Nerve damage leading to peripheral neuropathy is more often linked to chemotherapy, particularly agents like vincristine or cisplatin, rather than radiation therapy. Radiation to the neck primarily affects tissues in the irradiated field, such as the oral mucosa.
C. Mouth ulcers: Radiation to the neck frequently causes mucositis, leading to painful mouth ulcers due to the direct impact on rapidly dividing mucosal cells. Clients may experience pain, difficulty swallowing, and increased risk of infection as a result of mucosal breakdown.
D. Decreased tear production: Radiation therapy to the neck is unlikely to directly affect the lacrimal glands. While radiation near the eyes can cause dry eyes, treatment focused on the neck primarily impacts the oral mucosa, salivary glands, and throat rather than tear production.
Correct Answer is B
Explanation
A. Closing the inline clamp is necessary when the catheter is not in use to prevent air embolism, but it is not a required step before administering medication. The nurse should focus on flushing and checking for patency before medication administration.
B. Flushing the catheter with 10 mL of 0.9% sodium chloride before and after medication administration helps maintain patency, prevents occlusion, and ensures the catheter is functioning properly. This step is essential to avoid complications such as clot formation.
C. Applying a local anesthetic is not needed for routine medication administration through a nontunneled percutaneous central catheter. Anesthetic use is typically reserved for procedures like catheter insertion or painful dressing changes.
D. Donning sterile gloves is not required for medication administration through a central line. Clean gloves are sufficient, while sterile technique is reserved for dressing changes and catheter insertions.
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