A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider?
Creatinine 0.8 mL/dL
Weight gain 1.1 kg (2.4 lb) in 24 hr
Peripheral pulses 2+ bilaterally
Urine specific gravity 1.045
The Correct Answer is B
Weight gain 1.1 kg (2.4 lb) in 24 hours indicates fluid retention and possible volume overload, which can worsen kidney function and cause complications such as hypertension, pulmonary edema, and heart failure. The nurse should report this finding to the provider and monitor the client's vital signs, fluid intake and output, and electrolyte levels.
Creatinine 0.8 mL/dL is within the normal range for adults and does not indicate kidney impairment. Peripheral pulses 2+ bilaterally are normal and do not suggest any vascular problems. Urine specific gravity 1.045 is slightly high but not abnormal for a client with acute kidney failure, as it reflects the reduced ability of the kidneys to dilute urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: This choice suggests that the provider will prescribe a different medication regimen. However, this is not necessarily the case. Rifampin is a first-line medication for tuberculosis and its side effects, including the discoloration of body fluids, are well-known and expected. Therefore, it is unlikely that the provider would change the medication regimen solely based on this side effect.
Choice B rationale: This is the correct answer. Rifampin, an antibiotic used to treat tuberculosis, can cause a harmless red-orange discoloration of body fluids, including urine, sweat, tears, and saliva. This is an expected side effect of the medication and does not indicate any harm or toxicity. It is important for the nurse to reassure the client that this is a normal occurrence and does not require any changes to the medication regimen.
Choice C rationale: This choice suggests that the red-orange discoloration of the client’s saliva may indicate possible medication toxicity. However, this is not accurate. While rifampin can have serious side effects, including liver damage and severe gastrointestinal upset, the discoloration of body fluids is not a sign of toxicity. It is a harmless side effect of the medication.
Choice D rationale: This choice suggests that the client will need to increase her fluid intake to resolve the problem. However, increasing fluid intake will not change the discoloration caused by rifampin. The discoloration is a result of the medication itself and is not influenced by the client’s hydration status.
Correct Answer is D
Explanation
Valsartan is an angiotensin II receptor blocker that lowers blood pressure by blocking the vasoconstrictive and aldosterone-secreting effects of angiotensin II. Loweringblood pressure reduces the workload of the heart and improves cardiac function in patients with heart failure . Decreased urinary output, increased heart rate, and increased potassium level are not expected outcomes of valsartan therapy and may indicate worsening of heart failure or adverse effects of the medication.
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