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 C

Explanation

Toddlers often experience separation anxiety when separated from their primary caregivers. Having the parents stay with the child in the hospital, commonly known as rooming in, can provide a sense of security and familiarity, which helps alleviate separation anxiety. It allows the child to have a consistent presence and promotes a nurturing and comforting environment.

While explaining procedures and routines can be helpful, it may not fully address the underlying separation anxiety experienced by the toddler. Providing for privacy and encouraging contact with children the same age may not directly address the primary source of anxiety, which is being separated from the parents.

A. Out of bed three times daily & ad lib. B. Assess neurological status every 4 hours. C. Logroll only to change position. D. Monitor vital signs every 4 hours.

Correct Answer is A

Explanation

After spinal fusion surgery, it is important to limit the patient's activity and movement to allow for proper healing and to prevent complications. The order to have the patient out of bed three times daily and ad lib (as desired) is not appropriate immediately after surgery.

The other orders listed are appropriate for the postoperative care of a patient who has undergone spinal fusion surgery:

Assess neurological status every 4 hours: This is important to monitor for any changes in neurological function, which could indicate complications such as nerve damage or spinal cord compression.
Logroll only to change position: Logrolling is a technique used to move patients with spinal fusion surgery while keeping their spine aligned and minimizing stress on the surgical site. This order is appropriate to ensure proper positioning and prevent injury to the surgical area.
Monitor vital signs every 4 hours: Monitoring vital signs helps to assess the patient's overall condition and detect any signs of complications such as bleeding or infection.

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

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Naxlex Comprehensive Predictor Exams

An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to:

Correct Answer is C

Explanation

The nurse is caring for an adolescent diagnosed with scoliosis who just arrived to the floor from the recovery room after a Spinal fusion surgery. The nurse should question which physician order?

Correct Answer is A

Explanation

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