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

Answer and Explanation

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.

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Correct Answer is D

Explanation

The nurse should plan to confirm the correct position of the line by obtaining a blood sample, as this is one of the methods to verify placement and patency of a central venous catheter. The nurse should also instruct the client to perform a Valsalva maneuver (bearing down) as the catheter is inserted, place the head of the client's bed higher than 30 degrees, and cleanse the site with an antiseptic solution such as chlorhexidine.

A. Bradycardia B. Hypertension C. Chills D. Back pain

Correct Answer is D

Explanation

Back pain is a common symptom of a hemolytic transfusion reaction, which occurs when the recipient's immune system attacks and destroys the donor's red blood cells. Other symptoms include fever, chills, dyspnea, chest pain, hypotension, tachycardia, hemoglobinuria, and jaundice. A hemolytic transfusion reaction is a medical emergency that requires immediate intervention.

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A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

Correct Answer is D

Explanation

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