A client with acute kidney injury (AKI) has a blood pressure of 76/55 mm Hg. The primary health care provider prescribed 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client starts to develop shortness of breath. What is the nurse's priority action?
Decrease the rate of the IV infusion.
Calculate the mean arterial pressure (MAP).
Take the client's pulse.
Ask for insertion of a pulmonary artery catheter.
The Correct Answer is A
Rationale:
A. The development of shortness of breath during a rapid IV infusion of normal saline indicates possible fluid overload and pulmonary edema, especially in a client with acute kidney injury (AKI) who has impaired fluid excretion. The nurse’s priority action is to slow or decrease the rate of the IV infusion to prevent further respiratory compromise while maintaining perfusion. After doing so, the nurse should notify the healthcare provider for reassessment and potential adjustment of fluid orders.
B. Calculating the mean arterial pressure (MAP) can help assess perfusion status but does not address the immediate respiratory distress. This is a secondary assessment step after the client is stabilized.
C. Checking the pulse provides limited information in this situation and does not address the cause of the client’s respiratory distress or prevent worsening pulmonary edema.
D. Inserting a pulmonary artery catheter is an invasive diagnostic procedure that requires provider order and is not an immediate nursing intervention for acute shortness of breath.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Itching (pruritus) in CKD is caused by uremic toxin buildup and high phosphorus levels. While uncomfortable, it is not immediately life-threatening.
B. Blood pressure of 158/90 mm Hg indicates hypertension, which is a chronic issue in CKD but does not require immediate intervention compared with acute complications.
C. Halitosis and stomatitis are signs of uremia, common in CKD, but they are not acutely dangerous and can be managed after more urgent needs are addressed.
D. Kussmaul respirations are deep, labored breathing that occur in response to metabolic acidosis, a serious CKD complication due to the kidneys’ inability to excrete acid. This is a life-threatening condition requiring immediate assessment and intervention.
Correct Answer is A
Explanation
Rationale:
A. The development of shortness of breath during a rapid IV infusion of normal saline indicates possible fluid overload and pulmonary edema, especially in a client with acute kidney injury (AKI) who has impaired fluid excretion. The nurse’s priority action is to slow or decrease the rate of the IV infusion to prevent further respiratory compromise while maintaining perfusion. After doing so, the nurse should notify the healthcare provider for reassessment and potential adjustment of fluid orders.
B. Calculating the mean arterial pressure (MAP) can help assess perfusion status but does not address the immediate respiratory distress. This is a secondary assessment step after the client is stabilized.
C. Checking the pulse provides limited information in this situation and does not address the cause of the client’s respiratory distress or prevent worsening pulmonary edema.
D. Inserting a pulmonary artery catheter is an invasive diagnostic procedure that requires provider order and is not an immediate nursing intervention for acute shortness of breath.
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