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)

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Notify the surgeon that the informed consent process is not complete.The nurse should inform the surgeon because the surgeon is responsible for ensuring that the patient has adequate information and understands the procedure. It is not appropriate for the nurse to proceed with the consent process if the patient has questions or uncertainties.

B. Notify the operating room nurse to give a more complete explanation of the procedure.While the operating room nurse plays a role in the surgical process, it is the surgeon’s responsibility to provide a complete explanation of the procedure.

C. Provide a thorough explanation of the planned surgical procedure.While it’s important to provide information, the nurse is not authorized to explain the surgical procedure in detail. The surgeon should explain the surgery, as they have the training and knowledge to address all aspects of the procedure and answer any specific questions.

D. Give the prescribed preoperative antibiotics and withhold sedative medications.Administering preoperative medications, including antibiotics, without completed informed consent would be inappropriate. The patient must fully understand the procedure and consent to it before any medications are given.

A. Asking for nausea B. Evaluating for sacral redness C. Checking the respiratory rate D. Auscultating bowel sounds

Correct Answer is C

Explanation

Morphine is a potent opioid analgesic that can depress the respiratory system. Respiratory depression is a potential adverse effect of morphine, and it is essential for the nurse to monitor the patient's respiratory rate regularly to ensure adequate oxygenation and prevent respiratory complications.

By checking the respiratory rate, the nurse can assess if the patient is breathing adequately and detect any signs of respiratory depression. If the respiratory rate is significantly decreased or the patient shows signs of respiratory distress (e.g., shallow or irregular breathing), immediate intervention is necessary to address the situation promptly.

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The nurse is admitting a client diagnosed with acute renal failure (ARF). The nursing assessment will prioritize ...

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

Correct Answer is A

Explanation

The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient controlled analgesia (PCA). What action by the nurse is a priority?

Correct Answer is C

Explanation

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