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
Explanation
Sodium is the major extracellular electrolyte in the body.
It is responsible for maintaining the extracellular fluid volume, and also for regulation of the membrane potential of cells.
Sodium is exchanged along with potassium across cell membranes as part of active transport.
Choice B is wrong because potassium is mainly an intracellular ion.
It is important for nerve and muscle function, but it is not the predominant electrolyte in the extracellular fluid.
Choice C is wrong because calcium is not the major electrolyte in the extracellular fluid.
Calcium is mostly found in bones and teeth, where it forms a mineral reserve with phosphate.
Calcium also plays a role in muscle contraction, blood clotting, and enzyme activity.
Choice D is wrong because magnesium is not the major electrolyte in the extracellular fluid.
Magnesium is mostly found in bones, where it helps to stabilize the structure of ATP2.
Magnesium also participates in enzyme reactions, nerve and muscle function, and protein synthesis.
Correct Answer is B
Explanation
This is because hyperkalemia is a condition where the blood potassium level is too high.
This can cause cardiac arrhythmias, muscle weakness, and paralysis. Therefore, the nurse should administer intravenous insulin and glucose to lower the blood potassium level by shifting it into the cells.
Choice A is wrong because encouraging the patient to consume a high- potassium diet would increase the blood potassium level and worsen the condition.
Choice C is wrong because administering a potassium-sparing diuretic would prevent the excretion of excess potassium and aggravate the hyperkalemia.
Choice D is wrong because encouraging the patient to limit fluid intake is not relevant to the management of hyperkalemia and may cause dehydration.
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