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
Choice a.This response may come across as challenging or confrontational. While the nurse is asking for more information, the phrasing could inadvertently put the client on the defensive. It doesn't validate the client's feelings and may not encourage a productive dialogue.
- Choice b. “Suggesting peer support or mentorship from someone who has gone through a similar experience could be beneficial in some situations, as it may help the client feel less isolated.
- Choice c. “Most people can adjust following this surgery.” may be true, but it does not acknowledge the client’s individual experience and feelings. It may also sound dismissive or minimizing of the client’s challenges.
- Choice d. “You are upset. We can talk about this later.” may be intended to give the client some space, but it does not convey empathy or support. It may also make the client feel rejected or ignored.
Correct Answer is D
Explanation
The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.
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