The nurse is admitting a client diagnosed with acute renal failure (ARF). The nursing assessment will prioritize ...
Urine output and electrolyte levels.
Understanding of how to prevent falls.
Peripheral vascular perfusion and pain.
Risk for bleeding and white blood cell count (WBC)
The Correct Answer is A
Acute renal failure is characterized by a sudden decline in kidney function, resulting in the inability of the kidneys to adequately filter waste products and maintain fluid and electrolyte balance. Monitoring urine output is essential in assessing kidney function and determining the severity of renal failure. A decrease in urine output or anuria may indicate worsening renal function and the need for immediate interventions.
Assessing electrolyte levels, such as sodium, potassium, calcium, and phosphorus, is crucial because renal failure can disrupt the balance of these electrolytes in the body. Imbalances can lead to complications such as electrolyte abnormalities, cardiac dysrhythmias, and neuromuscular disturbances. Prompt identification and management of electrolyte imbalances are essential in preventing further complications and supporting optimal patient outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hemoglobin A1C is a blood test that provides an average blood glucose level over the past 2-3 months. Regular monitoring of A1C levels helps to assess the effectiveness of lifestyle modifications and treatment plans and guides adjustments in management if necessary.
Daily exercise is another essential aspect of managing pre-diabetes. Regular physical activity helps improve insulin sensitivity, promotes weight management, and reduces the risk of developing type 2 diabetes. The nurse should educate patients on the importance of incorporating physical activity into their daily routine and provide recommendations on suitable exercise types and durations.
While other options may be relevant for patients with diabetes, they are not specifically tailored to pre-diabetes, which is a condition where blood glucose levels are higher than normal but not yet meeting the criteria for diabetes.
Hypoglycemia and injection site infection are more relevant concerns for individuals with diabetes who require insulin or other medications to manage their blood sugar levels. Increasing carbohydrate intake and administering insulin are not appropriate recommendations for pre-diabetes management, as they can contribute to elevated blood glucose levels.
Correct Answer is C
Explanation
Suctioning secretions away from the suture line helps maintain the surgical site's cleanliness and promotes healing. It helps prevent accumulation of mucus or oral secretions that can interfere with the healing process and increase the risk of infection. The nurse should use a gentle suctioning technique to avoid disrupting the surgical site.
Applying Neosporin to the surgical site is not typically recommended unless specifically prescribed by the healthcare provider. It is important to follow the provider's instructions regarding wound care.
Applying elbow immobilizers when not being held is not necessary for cleft lip surgery. Elbow immobilizers are usually used in other surgical procedures or for other reasons, such as preventing contractures.
Feeding increased amounts of formula to prevent weight loss is not an appropriate intervention for the first few days after cleft lip surgery. The surgical site may be sensitive, and the child may experience difficulty with feeding initially. The nurse should provide guidance and support for feeding techniques appropriate for the child, which may include using specialized bottles or positioning techniques.
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