The client has a history of Wilms tumor with left radical nephrectomy diagnosed at age five for which he completed treatment nine months ago. A septic episode, while undergoing treatment for his Wilms tumor, resulted in an acute kidney injury. This Injury, along with antibiotic therapy and chemotherapy, has resulted in chronic kidney disease. The client is followed by oncology and nephrology services.
For each nursing action, click to indicate whether the action is indicated or contraindicated for this client's plan of care.
Each row must have only one response option selected.
Continuous pulse oximetry monitoring
Calculation of intake and output
Daily weights
IV 0.9% normal saline continuous infusion at 100 mL/hr
IV potassium sparing diuretic
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Continuous pulse oximetry monitoring is indicated for assessing oxygen saturation and respiratory status, especially in a client with a history of chronic kidney disease and a previous septic episode. It helps monitor the client's respiratory function.
Calculation of intake and output is indicated to assess fluid balance, which is crucial in clients with chronic kidney disease and a history of acute kidney injury. It helps monitor fluid management.
Daily weights are indicated to monitor fluid retention and changes in the client's weight, which can be affected by the client's kidney condition and the administration of intravenous fluids.
IV 0.9% normal saline continuous infusion at 100 mL/hr is indicated to maintain hydration and promote renal function in clients with chronic kidney disease. It helps ensure adequate fluid balance.
IV potassium-sparing diuretics may be contraindicated because they can potentially affect electrolyte balance, and in some cases, they might not be suitable for clients with chronic kidney disease. The use of diuretics should be carefully evaluated and managed by the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Giving the injection in the arm, one to 2 inches below the acromion process, is a technique typically used for adults or older children. It may not be suitable for a toddler of this age.
B. Using a needle length of 1/2 inch is not appropriate for intramuscular injections in a toddler. It may not reach the muscle tissue, leading to ineffective administration.
C. Dividing the gluteal area into quarters and giving the injection into the upper outer quadrant is a technique typically used for older children and adults, not for toddlers. It's also important to avoid intramuscular injections in the gluteal area for young children due to the risk of injury to the sciatic nerve.
D. Administering the injection into the middle of the lateral aspect of the thigh is the preferred technique for intramuscular injections in toddlers. The thigh muscles are a safe and effective site for IM injections in this age group. The middle of the lateral aspect of the thigh is commonly chosen because it provides a sufficient muscle mass for proper absorption of the medication and minimizes the risk of injury to nerves or vessels. This technique is recommended for toddlers who are walking and have developed sufficient muscle mass in the thigh area.
Correct Answer is B
Explanation
A. Regular syringe feedings alone do not necessarily promote rapid weight gain, and their appropriateness depends on the underlying cause of FTT and the healthcare provider's recommendations.
B. Breast milk provides adequate calories for the child.
Breast milk is an excellent source of nutrition for infants, providing essential nutrients and calories needed for healthy growth and development. It is generally well-tolerated and suitable for most infants. Encouraging breastfeeding, especially if the infant is not exclusively breastfed, can be a valuable approach in managing FTT.
C. Fruit juice, particularly in excess, may not be recommended for infants with FTT as it can be high in sugars and low in essential nutrients. It is not a primary intervention for FTT.
D. High-calorie formula can be considered for infants with FTT, but it should be prescribed and monitored by a healthcare provider. Simply using high-calorie formula without proper guidance is not an appropriate intervention.
Breast milk is a valuable and appropriate source of nutrition for infants with FTT, and the nurse should support and encourage its use while monitoring the infant's growth and progress closely.
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