A client with acute kidney injury (AKI) is admitted with an elevated heart rate and an elevated blood pressure. Which intervention should the practical nurse (PN) implement?
Monitor daily sodium intake.
Record usual eating patterns.
Document abdominal girth.
Measure and document urinary output.
The Correct Answer is D
A. Monitoring daily sodium intake is important for managing AKI, but it is not the immediate priority when addressing acute changes in heart rate and blood pressure.
B. Recording usual eating patterns is not relevant to the immediate concern of elevated heart rate and blood pressure in the context of AKI.
C. Documenting abdominal girth is relevant for assessing fluid status and potential complications like ascites, but it is not the first priority for addressing the acute symptoms of elevated heart rate and blood pressure.
D. Measuring and documenting urinary output is the most critical intervention because it provides essential information on kidney function and fluid balance, which directly impacts heart rate and blood pressure management in AKI.
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Related Questions
Correct Answer is D
Explanation
A. Telling the client to focus on the positive aspects of life might seem dismissive of the client's current emotional state and concerns.
B. Providing information about support groups is helpful but should follow an initial supportive and empathetic response.
C. Allowing the client privacy may be necessary later, but initially, it is important to offer support and presence.
D. Sitting quietly with the client and answering any questions demonstrates empathy, support, and availability, helping the client process the new diagnosis and feel less isolated.
Correct Answer is B
Explanation
A. Isoniazid can cause side effects like peripheral neuropathy, but ringing in the ears is not a common symptom of this medication.
B. Gentamicin can cause ototoxicity, which includes symptoms such as ringing in the ears (tinnitus). This side effect is significant and should be reported to the healthcare provider for further evaluation.
C. Pyridoxine is used to prevent neuropathy caused by isoniazid and does not cause ringing in the ears.
D. Rifampin is an antitubercular medication but is not commonly associated with tinnitus as a side effect. The immediate concern with ringing in the ears is related to gentamicin.
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