A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?
Place the patient on a cardiac monitor.
Insert a urinary retention catheter.
Give the prescribed spironolactone.
Administer epoetin alfa (Epogen).
The Correct Answer is A
Choice A rationale
In the case of hyperkalemia, which can cause fatal cardiac arrhythmias, the most immediate nursing action is to place the patient on a cardiac monitor. This allows for continuous monitoring of the heart's rhythm and immediate detection of any life-threatening changes, which is crucial for timely intervention.
Choice B rationale
Inserting a urinary retention catheter may be necessary for managing oliguria, but it is not the most urgent action when compared to the potential cardiac risks associated with hyperkalemia.
Choice C rationale
Administering spironolactone, a potassium-sparing diuretic, could be part of the treatment for hyperkalemia, but it is not the first action to take. Spironolactone works more slowly and does not address the immediate risk of cardiac arrhythmias.
Choice D rationale
Epoetin alfa (Epogen) is used to treat anemia, particularly in chronic kidney disease, to increase red blood cell production. However, it does not have an immediate effect and is not the priority in the presence of hyperkalemia and potential cardiac complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Storing the medication at room temperature is a practical instruction but does not explain the therapeutic purpose of the medication, which is essential for patient understanding.
Choice B rationale
Epoetin alfa (Procrit) is used to treat anemia associated with chronic kidney disease by supplementing erythropoietin, a hormone the damaged kidneys can no longer produce effectively. This is the most informative statement for the patient's understanding of the medication's purpose.
Choice C rationale
While epoetin alfa can improve anemia and potentially improve quality of life, it does not directly delay the need for dialysis, which is determined by overall kidney function and not solely by the presence of anemia.
Choice D rationale
Epoetin alfa does not have a role in preventing AV fistula clotting. It is specifically used to stimulate red blood cell production and has no direct effect on clotting mechanisms.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Immobility is a significant risk factor for DVT as it can lead to stagnation of blood in the veins, increasing the risk of clot formation.
Choice B rationale
High calcium intake is not typically associated with an increased risk of DVT. Instead, factors like immobility, certain medications, and medical conditions are more influential.
Choice C rationale
Oral contraceptive use, especially those containing estrogen, can increase the risk of DVT due to their effect on blood clotting mechanisms.
Choice D rationale
A BMI of 20 is considered within the normal range and is not a risk factor for DVT. Obesity, which is a BMI of 30 or higher, would be a risk factor.
Choice E rationale
Hypertension itself is not a direct risk factor for DVT. However, it can be associated with other health conditions that may increase the risk of thrombosis.
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