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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale
Reviewing serum protein levels can provide valuable information about a client’s nutritional status and liver function. However, in the context of a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness, and has a high polymorphonuclear leukocyte count in ascitic fluid, initiating antibiotic therapy is the priority.
Choice B rationale
Beginning abdominal girth measurements can be useful for monitoring the progression of ascites in a client with liver disease. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
Choice C rationale

Initiating antibiotic therapy is the correct intervention in this case. The client’s symptoms and the high polymorphonuclear leukocyte count in the ascitic fluid suggest spontaneous bacterial peritonitis, a serious complication of cirrhosis that requires immediate antibiotic treatment.
Choice D rationale
Assessing neurological status is important in clients with liver disease, as they are at risk for hepatic encephalopathy. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.

A. Addiction B. Compulsion C. Obsession D. Phobia

Correct Answer is B

Explanation

Choice A rationale
Addiction refers to a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The intricate handwashing ritual that lasts two hours or more described by the client does not indicate substance use or dependency, which are common characteristics of addiction.
Choice B rationale

Compulsion refers to repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The client’s intricate handwashing ritual that lasts two hours or more and their concern about maintaining cleanliness align with the definition of a compulsion.
Choice C rationale
Obsession refers to recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and unwanted. While the client’s concern about maintaining cleanliness could potentially be seen as an obsession, the act of handwashing is a behavior, which aligns more with the definition of a compulsion.
Choice D rationale
Phobia refers to an extreme or irrational fear of or aversion to something. The client’s behavior does not indicate an extreme or irrational fear but rather a compulsion to maintain cleanliness through an intricate handwashing ritual.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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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?