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 D
Explanation
Choice A rationale
Chest pain that is relieved with eating or drinking water is not typically indicative of a complication from a peptic ulcer. This symptom may be related to conditions like gastroesophageal reflux disease (GERD).
Choice B rationale
Burning epigastric pain after eating is a common symptom of a peptic ulcer and, while uncomfortable, does not usually require an urgent change in the plan of care unless it significantly worsens or is accompanied by other concerning symptoms.
Choice C rationale
Back pain after eating can be associated with a peptic ulcer if the ulcer is located at the back of the stomach or the pain radiates; however, it does not typically warrant an urgent change in care without other symptoms.
Choice D rationale
A rigid abdomen and vomiting following indigestion can indicate a perforated ulcer, which is a medical emergency. This requires immediate intervention and possibly surgical consultation, thus warranting an urgent change in the nursing plan of care.
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale
While family history can contribute to the risk of developing certain conditions, it is not a direct risk factor for peptic ulcer disease.
Choice B rationale
A long-term smoking history is a known risk factor for peptic ulcer disease as it can increase gastric acid secretion and reduce the production of substances that protect the stomach lining.
Choice C rationale
The client denies alcohol use; therefore, it is not a contributing risk factor in this case. However, alcohol use is generally a risk factor for PUD due to its irritating effect on the stomach lining.
Choice D rationale
Being positive for Helicobacter pylori is one of the strongest risk factors for peptic ulcer disease. This bacterium damages the protective mucosal layer of the stomach and duodenum, leading to chronic inflammation and allowing acid to injure the underlying tissue. It is the leading cause of most gastric and duodenal ulcers worldwide.
Choice E rationale
NSAID use is a well-established risk factor for peptic ulcer disease as these medications can disrupt the protective lining of the stomach, leading to ulcers.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.