The nurse is developing a plan of care for a client diagnosed with acute renal failure (ARF). Which statement would be an appropriate outcome for the client?

Electrolytes are within normal limits.

Blood pressure is decreased to 120/80

Decrease of pain by 3 points on a 1-10 scale.

The client will understand how to care for the AV fistula

Answer and Explanation

The Correct Answer is A

A. Electrolytes are within normal limits: Acute Renal Failure (ARF) leads to electrolyte imbalances (↑ K+, ↑ BUN/creatinine, metabolic acidosis). A successful treatment goal is restoring normal electrolyte balance.

B. Blood pressure is decreased to 120/80. BP control is important but not the primary goal in ARF.

C. Decrease of pain by 3 points on a 1-10 scale. Pain control is important, but not the main indicator of ARF improvement.

D. The client will understand how to care for the AV fistula. This applies to chronic kidney disease clients on hemodialysis, not ARF management.

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Correct Answer is D

Explanation

A. "If I stop sweating, I should call 911 or get to the Emergency Department quickly.” An absence of sweating can indicate heat stroke, a medical emergency.

B. "If this happens in the future, lying in cool water would be beneficial.” Cooling measures like cold baths, ice packs, and shade help reduce body temperature.

C. “Using salt tablets to replenish my electrolytes may lead to nausea and vomiting.” Salt tablets can irritate the stomach and cause nausea, vomiting, and hypernatremia.

D. "Drinking water is the best way to improve sodium intake.” While water helps with rehydration, it does not replace lost sodium. Excessive water intake without electrolytes can cause hyponatremia, leading to confusion, seizures, or coma. Electrolyte-containing drinks (e.g., sports drinks, oral rehydration solutions) are better choices.

A. Diarrhea B. Shivering C. Hypotension D. Vomiting

Correct Answer is B

Explanation

A. Diarrhea: Diarrhea is not a common side effect of cooling therapy and does not indicate a need to stop treatment.

B. Shivering: Shivering counteracts the cooling effect of the blanket, increasing body temperature and metabolic demand. This indicates the treatment is ineffective and needs adjustment.

C. Hypotension: While cooling can cause vasodilation and lower blood pressure, mild hypotension does not immediately necessitate stopping treatment.

D. Vomiting: Vomiting may be due to fever-related illness but is not a direct indicator that cooling should be stopped.

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The nurse is developing a plan of care for a client diagnosed with acute renal failure (ARF). Which statement would be an appropriate outcome for the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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