A patient with acute renal failure (ARF) is admitted due to uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale.
What is the most important intervention for the nurse to include in this patient’s plan of care?
Monitor the patient’s cardiac activity via telemetry.
Assess glucose via fingerstick every 4 to 6 hours.
Evaluate hourly urine output for return of normal renal function.
Maintain venous access with an infusion of normal saline.
The Correct Answer is A
Choice A rationale
Monitoring the patient’s cardiac activity via telemetry is the most important intervention for a patient with acute renal failure (ARF), uncontrolled type 1 diabetes mellitus, and hyperkalemia who is receiving an IV dose of regular insulin. Hyperkalemia can cause cardiac arrhythmias and other cardiac complications. Therefore, continuous cardiac monitoring is crucial to detect any changes in heart rhythm or rate that could indicate worsening hyperkalemia.
Choice B rationale
While assessing glucose via fingerstick every 4 to 6 hours is important for a patient with uncontrolled type 1 diabetes mellitus, it is not the most important intervention in this scenario. The patient’s hyperkalemia and ARF pose more immediate risks.
Choice C rationale
Evaluating hourly urine output for return of normal renal function is an important part of monitoring a patient with ARF34. However, in the context of hyperkalemia and the administration of insulin, cardiac monitoring is more critical.
Choice D rationale
Maintaining venous access with an infusion of normal saline is a standard nursing intervention for most hospitalized patients, but it is not the most important intervention in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Anticipating and monitoring for hypothermia is the most crucial nursing intervention to include in the care plan for a patient who is 12 hours post-thyroidectomy. The thyroid gland plays a significant role in regulating the body’s metabolism, including temperature regulation. After a thyroidectomy, the body may struggle to regulate temperature, leading to hypothermia. The nurse should monitor the patient’s temperature regularly and provide warming measures as needed.
Choice B rationale
Preparing to administer radioactive iodine treatments is not the most crucial intervention at this time. Radioactive iodine is typically used as a treatment for hyperthyroidism or thyroid cancer, not as an immediate post-operative intervention.
Choice C rationale
Resuming antithyroid drug therapy is not the most crucial intervention at this time. Antithyroid drugs are used to treat hyperthyroidism, and their use would need to be evaluated based on the reason for the thyroidectomy and the patient’s post-operative thyroid hormone levels.
Choice D rationale
Maintaining a semi-Fowler position can be beneficial for comfort and respiratory function post-operatively, but it is not the most crucial intervention. The nurse should assist the patient to a comfortable position and encourage regular deep breathing and coughing exercises to prevent respiratory complications.
Correct Answer is C
Explanation
Choice A rationale
While obtaining a serum drug screen might be helpful in confirming the presence of benzodiazepines or other substances, it is not the most immediate concern in a client experiencing severe agitation and tremors due to withdrawal.
Choice B rationale
Naloxone is an opioid antagonist and would not be effective in managing withdrawal symptoms from benzodiazepines.
Choice C rationale
Seizure precautions should be initiated as withdrawal from benzodiazepines can lead to severe withdrawal symptoms, including seizures. Therefore, ensuring the safety of the client by initiating seizure precautions is the best initial nursing action.
Choice D rationale
While education is an important part of nursing care, in this situation, the client’s immediate physical needs take precedence.
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