The client has been admitted to the hospital with a diagnosis of acute kidney injury (AKI).
Which of the following is a priority nursing intervention?
Administer pain medication.
Monitor urine output.
Encourage ambulation.
Assist with meals.
The Correct Answer is B
This is a priority nursing intervention for a client with acute kidney injury (AKI) because it helps to assess the renal function and fluid status of the client. Urine output is also an indicator of the response to treatment and the need for further interventions.
Choice A is wrong because pain medication is not a priority intervention for AKI unless the client has other conditions that cause pain.
Pain medication may also have adverse effects on the kidney function and should be used with caution.
Choice C is wrong because ambulation is not a priority intervention for AKI and may not be appropriate for a client who is fluid overloaded or hypotensive.
Ambulation may also increase the risk of falls and injury in a client who is confused or fatigued.
Choice D is wrong because assisting with meals is not a priority intervention for AKI and may not be necessary for a client who has adequate oral intake.
A client with AKI may also have dietary restrictions such as low protein, low potassium, low sodium, and low phosphorus, which should be considered when providing meals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
The nurse should anticipate administering 0.9% sodium chloride solution and regular insulin infusion to a client with diabetic ketoacidosis (DKA).
Choice A is wrong because 0.45% sodium chloride solution is a hypotonic fluid that can cause cerebral edema in DKA patients.
Choice C is wrong because 5% dextrose in water solution can increase blood glucose levels and worsen hyperglycemia in DKA patients.
Choice D is wrong because lactated Ringer’s solution contains lactate, which can be converted to bicarbonate and cause metabolic alkalosis in DKA patients.
Normal ranges for blood glucose, pH, bicarbonate, and ketones are as follows3: Blood glucose: 70-130 mg/dL before meals, and less than 180 mg/dL after meals pH: 7.35-7.45
Bicarbonate: 22-26 mEq/L Ketones: negative or trace
Correct Answer is B
Explanation
Performing hand hygiene before and after handling the dialysis equipment is essential to prevent infection in peritoneal dialysis.
Hand washing and appropriate use of a mask can help avoid peritonitis, which is a serious complication of peritoneal dialysis.
Choice A is wrong because administering antibiotics prophylactically is not recommended for peritoneal dialysis patients, as it can increase the risk of antibiotic resistance and adverse effects.
Choice C is wrong because allowing the client to handle the dialysis equipment independently may increase the risk of contamination and infection.
The client should be supervised and instructed by a nurse on how to use sterile technique when connecting and disconnecting the transfer set.
Choice D is wrong because discontinuing the peritoneal dialysis if the client develops a fever may worsen the client’s condition and lead to fluid overload and electrolyte imbalance.
The client should be evaluated for signs of infection and treated accordingly.
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