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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Smoking is a well-established risk factor for colorectal cancer. The carcinogens in tobacco smoke can lead to the formation of cancerous cells in the colon and rectum.
Choice B rationale
Obesity increases the risk of colorectal cancer, possibly due to chronic low-level inflammation associated with excess body fat, which can contribute to cancer development.
Choice C rationale
Limiting alcohol intake to less than four drinks per week is actually a protective measure against colorectal cancer, not a risk factor.
Choice D rationale
A high intake of red meat, particularly more than seven servings per week, has been linked to an increased risk of colorectal cancer due to compounds formed during digestion that can damage the lining of the colon and rectum.
Choice E rationale
A diet high in fruits, vegetables, and grains is generally considered protective against colorectal cancer due to the fiber and nutrients they provide, not a risk factor.
Correct Answer is C
Explanation
Choice A rationale
Elevated blood pressure is a common finding in cardiovascular conditions but is not specifically indicated by the presence of crackles, dyspnea on exertion, or an S3 gallop.
Choice B rationale
A decreased respiratory rate is not typically associated with the presence of crackles and dyspnea; these symptoms are more indicative of increased work of breathing and potential fluid overload.
Choice C rationale
Pitting edema is a classic sign of fluid retention, which can be associated with heart failure. The presence of crackles, dyspnea on exertion, and an S3 gallop are clinical indicators that suggest heart failure, making pitting edema a likely finding.
Choice D rationale
An irregular pulse may be found in various cardiac conditions but is not directly suggested by the symptoms described. The presence of an S3 gallop is more indicative of heart failure, which is commonly associated with fluid overload signs such as pitting edema.
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