A client is in the oliguric phase of acute kidney injury (AKI) which was caused by massive tissue trauma. The nurse notes peaked T-waves and a widened QRS complex on the cardiac monitor. What is the first action the nurse should take?
Check the client's most recent potassium level
Administer a bolus of 1,000 mL of normal saline
Administer potassium chloride intravenously (IV)
Administer sodium polystyrene sulfonate (Kayexalate)
The Correct Answer is A
A. Peaked T-waves and a widened QRS complex on an ECG are often signs of hyperkalemia, which is an elevated potassium level in the blood. This can be a serious complication of acute kidney injury (AKI), especially in the oliguric phase when the kidneys are unable to effectively excrete potassium.A
B. While fluid management is important in AKI, administering a bolus of normal saline is not the first priority in the presence of suspected hyperkalemia. The primary concern is to address the electrolyte imbalance.
C. Administering potassium chloride would worsen hyperkalemia and should be avoided.
D. Kayexalate is a medication used to treat hyperkalemia by exchanging sodium ions for potassium ions in the gastrointestinal tract. However, checking the potassium level is the first step in confirming the diagnosis and determining the appropriate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
. Shellfish allergies are related to potential reactions to iodinated contrast media used in imaging studies, such as CT scans, rather than to spirometry. Spirometry does not involve contrast media or shellfish, so this question is not pertinent for this test.
B.A Metal implants are typically a concern for imaging tests like MRI, which involve strong magnetic fields. Spirometry, however, does not involve any imaging or use of magnetic fields, so metal implants do not affect spirometry results. Thus, this question is not relevant for spirometry preparation.
C. This is a relevant question for spirometry testing. Bronchodilators are medications used to open the airways and improve breathing. They can affect spirometry results if taken shortly before the test. For accurate assessment, the nurse needs to know if the client has used any bronchodilators, as they might need to adjust the testing protocol or account for the medication's effects on lung function.
D. Spirometry does not typically involve enclosed spaces that would trigger claustrophobia, as it is a breathing test usually performed with the client sitting comfortably in an open space. Claustrophobia is more relevant to imaging studies like MRIs or CT scans, where the client might be in a confined space.
Correct Answer is B
Explanation
A. This blood pressure and heart rate are within normal ranges for most patients. For example, a blood pressure of 132/60 mmHg is slightly elevated on the systolic side but not critically so, and a heart rate of 90 beats per minute is within the normal range (60-100 beats per minute).
B. Continuous bladder irrigation is used to prevent clots and debris from obstructing the urinary tract after a TURP. If the output from the Foley catheter has stopped, it may indicate a blockage or clot in the catheter or bladder, which can lead to bladder distension, discomfort, and potential kidney damage.
Immediate reporting to the provider is crucial because this could indicate a severe complication.
C. Pain levels are subjective, and a pain level of 5/10 indicates moderate discomfort. While pain management is important, a pain level of 5/10 is not unusual after TURP, and it can often be managed with appropriate pain relief measures.
D. Pink-colored urine is not uncommon immediately following a TURP as a result of bleeding or irritation from the procedure. This finding can be expected and may not indicate an immediate complication.
However, if the urine color changes to bright red or if there is a significant increase in blood, it could be more concerning.
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