The nurse is assessing a patient with acute renal failure.
Which of the following would be a priority nursing intervention?
Administering a potassium-sparing diuretic.
Encouraging the patient to consume a high-sodium diet.
Monitoring urine output and fluid balance.
Administering intravenous antibiotics.
The Correct Answer is C
This is because acute renal failure is a condition where the kidneys lose their ability to filter waste and excess fluid from the blood. This can lead to fluid overload, electrolyte imbalances, and metabolic acidosis. Therefore, the nurse should monitor the patient’s urine output and fluid balance to assess the severity of the renal impairment and prevent complications.
Choice A is wrong because administering a potassium-sparing diuretic would worsen the patient’s hyperkalemia, which is a common complication of acute renal failure.
Choice B is wrong because encouraging the patient to consume a high-sodium diet would increase the patient’s fluid retention and blood pressure, which can further damage the kidneys.
Choice D is wrong because administering intravenous antibiotics is not a priority intervention for acute renal failure unless there is a specific indication of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because urinary catheters are a common source of catheter associated urinary tract infections (CAUTIs), which can lead to complications such as pyelonephritis, sepsis, and renal failure. Therefore, the nurse should remove the catheter as soon as possible to reduce the risk of infection and promote normal urinary function.
Choice B is wrong because ensuring that the catheter is properly secured to prevent accidental dislodgement is not a priority intervention for a patient with a urinary catheter.
While this is an important nursing action to prevent trauma and bleeding, it does not address the main complication of catheterization, which is infection.
Choice C is wrong because encouraging the patient to drink fluids to prevent dehydration is not a priority intervention for a patient with a urinary catheter.
While this is a good nursing practice to maintain hydration and renal perfusion, it does not affect the risk of infection associated with catheterization.
Choice D is wrong because administering antibiotics to prevent infection is not a priority intervention for a patient with a urinary catheter.
While this may be indicated for some patients who have signs and symptoms of UTI or who are at high risk of infection, it is not a routine measure for all patients with catheters and may contribute to antibiotic resistance.
Correct Answer is A
Explanation
Fluid overload, also called hypervolemia, is a condition in which the body has too much water.
It can cause edema, hypertension, shortness of breath, and cardiovascular problems.
Diuretics are medications that help the body remove excess fluid through urine.
They are commonly used to treat fluid overload caused by heart failure, kidney failure, cirrhosis, and other conditions.
Choice B is wrong because encouraging increased fluid intake would worsen the fluid overload and increase the risk of complications.
Choice C is wrong because providing a high-sodium diet would also worsen the fluid overload and increase the risk of complications.
Sodium is an electrolyte that regulates fluid balance in the body.
Excess sodium intake can cause water retention and increase blood pressure.
Choice D is wrong because elevating the affected extremities is not an appropriate intervention for fluid overload.
Elevating the extremities can help reduce swelling caused by local factors such as injury or inflammation, but it does not address the underlying cause of fluid overload.
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