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
Trousseau’s sign is a test for hypocalcemia that involves inflating a blood pressure cuff on the arm and observing for carpal spasm. A positive sign indicates low calcium levels in the blood, which can cause neuromuscular irritability.
Choice B is wrong because hyperactive deep tendon reflexes are a sign of hypomagnesemia, which is a low level of magnesium in the blood.
Choice C is wrong because hyperactive bowel sounds are a sign of hyperkalemia, which is a high level of potassium in the blood.
Choice D is wrong because muscle twitching can be caused by many factors, such as anxiety, caffeine, or electrolyte imbalance, and is not specific to hypocalcemia.
Correct Answer is C
Explanation
This is because intravenous potassium supplementation is indicated for patients with profound hypokalemia (plasma K+ <2.5 mmol/L) or cardiac arrhythmia. The rate of infusion should not exceed 10 mmol/hour to prevent complications such as hyperkalemia, cardiac arrhythmias, and phlebitis.
Choice A is wrong because monitoring urine output every 8 hours is not sufficient to prevent complications from intravenous potassium replacement therapy.
Urine output should be monitored more frequently (at least every 4 hours) to assess renal function and fluid balance.
Choice B is wrong because administering potassium via a bolus injection is dangerous and can cause fatal cardiac arrhythmias.
Potassium should never be given by intravenous push or intramuscular injection.
Choice D is wrong because encouraging the client to eat potassium-rich foods is not appropriate for patients receiving intravenous potassium replacement therapy.
Oral potassium supplementation is preferred for patients with mild to moderate hypokalemia (plasma K+ 2.5-3.5 mmol/L) who can eat and absorb oral potassium.
Potassium-rich foods include potatoes, legumes, juices, seafood, leafy greens, dairy, tomatoes and bananas.
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