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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Vegetarian lasagna with cheese and spinach, a tossed green salad with ranch dressing, and fresh fruit is a balanced meal. However, it may not be the best choice for a patient with type 2 diabetes due to the high carbohydrate content in the lasagna and the dressing.
Choice B rationale
Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie is not the best choice for a patient with type 2 diabetes. Fried foods and mashed potatoes are high in carbohydrates and fats, which can raise blood sugar levels.
Choice C rationale
Grilled fish with whole-grain brown rice, steamed broccoli, and a pear poached in red wine is a good choice for a patient with type 2 diabetes. This meal is balanced with lean protein, whole grains, and vegetables, which can help control blood sugar levels.
Choice D rationale
Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake is not the best choice for a patient with type 2 diabetes. Although the hamburger is lean, the whole-wheat bun and angel food cake are high in carbohydrates, which can raise blood sugar levels.
Correct Answer is A
Explanation
Choice A rationale
Hyperventilation leads to a decrease in the amount of carbon dioxide (CO2) in the blood. This causes the pH of the blood to increase, resulting in respiratory alkalosis.
Choice B rationale
Respiratory acidosis is caused by a buildup of CO2 in the blood, typically due to hypoventilation (under-breathing). This is not consistent with the patient’s symptoms of hyperventilation.
Choice C rationale
Metabolic alkalosis is typically caused by a significant loss of acid from the body, such as from prolonged vomiting. This is not consistent with the patient’s symptoms.
Choice D rationale
Metabolic acidosis is typically caused by an increase in acid production within the body or a loss of bicarbonate from the body, such as in diabetic ketoacidosis or kidney disease. This is not consistent with the patient’s symptoms.
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