A nurse is caring for four clients on a medical-surgical unit. Which of the following clients is at the highest risk for developing acute kidney injury?
A client who was admitted with pneumonia receiving cefazolin IV
A client who was admitted with dehydration from bacterial meningitis receiving vancomycin IV
A client who was admitted with uncontrolled atrial fibrillation on a diltiazem IV drip
A client who was admitted with an exacerbation of congestive heart failure receiving metoprolol PO
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Correct Actions:
B. Test the pH of gastric aspirate.
Explanation: Testing the pH of gastric aspirate helps confirm that the NG tube is correctly positioned in the stomach. A pH of 4 or less generally indicates gastric placement. This step is crucial to avoid complications like aspiration and ensure proper feeding.
E. Check the tube's placement and patency.
Explanation: Ensuring that the tube is correctly positioned and patent (not blocked) is essential before administering feedings. This involves aspirating some of the gastric contents to confirm placement and flushing the tube with water to verify it is clear and functioning properly.
Incorrect Actions:
A. Discard residual gastric contents.
Explanation: While it is important to measure gastric residuals to assess the stomach's ability to handle the feeding, residuals are not discarded. Instead, they are measured and then returned to the stomach unless otherwise specified by the healthcare provider.
C. Auscultate sounds.
Explanation: Auscultation of bowel sounds is not typically required immediately before administering enteral feedings. However, assessing bowel sounds periodically can be part of overall monitoring to ensure proper gastrointestinal function.
D. Warm the formula to body temperature.
Explanation: Enteral feeding formulas are generally administered at room temperature, although some facilities may have specific protocols for warming. Most guidelines do not require warming formula to body temperature.
Correct Answer is A
No explanation
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