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).

Answer and Explanation

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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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.

A. Tell the patient to clean the urethral area, void a small amount into the toilet, then void directly into a sterile container. B. Have the patient empty the bladder completely; then obtain the next urine specimen that the patient is able to void. C. Clean the area around the patient's meatus with a povidone-iodine (Betadine) swab and then have the patient void into a sterile specimen cup. D. Insert a short sterile "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen.

Correct Answer is A

Explanation

Choice A rationale
This method is the standard procedure for obtaining a clean-catch midstream urine specimen. The initial voiding washes away organisms near the meatus, and the midstream urine is less likely to be contaminated by bacteria from the skin or urethral area, providing a sample that more accurately represents the bacteria in the bladder.

Choice B rationale
Having the patient empty the bladder completely and then obtaining the next specimen does not ensure a clean-catch sample. This method could lead to contamination of the specimen with bacteria from the skin or urethral area.

Choice C rationale
Cleaning the area with povidone-iodine is not recommended for routine urine culture as it may kill some of the bacteria, leading to a false-negative result. The standard practice is to clean the area with mild soap and water.

Choice D rationale
Inserting a catheter is an invasive procedure and is not the first choice for obtaining a urine specimen. It is used when a patient is unable to provide a clean-catch specimen or if there are specific medical indications.

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A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 72-year-old patient was admitted with epigastric pain caused by a peptic ulcer. Which patient assessment warrants an urgent change in the nursing plan of care?

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Correct Answer is A

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