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 C
Explanation
A. Stating that the healthcare provider left specific instructions may come across as confrontational and does not address the client's emotional state. The focus should be on empathetic communication rather than emphasizing authority.
B. While acknowledging the client’s feelings is important, this response may not de-escalate the situation. It focuses on the necessity of ambulation rather than addressing the client's anger and offering support.
C. Offering to return in 30 minutes provides the client with a sense of control and acknowledges their feelings. It is a supportive and respectful approach that allows time for the client to calm down and prepares them for ambulation.
D. Explaining that ambulation is necessary to avoid complications can sound directive and may not help in managing the client's anger. It is more effective to acknowledge the client's feelings and offer to help at a later time.
Correct Answer is ["C","D"]
Explanation
A. Teaching the client with fluid restrictions how to measure urine output requires specialized knowledge and skills. This task should be performed by a licensed nurse to ensure accurate instruction and patient understanding.
B. Irrigating an indwelling urinary catheter involves sterile technique and specialized knowledge, which should be performed by a licensed nurse. This task requires specific training to prevent complications.
C. Transporting a urine culture sample to the laboratory can be safely assigned to a UAP. It involves routine tasks that do not require advanced clinical skills and is essential for timely processing of specimens.
D. Emptying the bedside drainage unit for a client with an indwelling urinary catheter can be performed by a UAP. This task involves basic care procedures that support patient hygiene and comfort.
E. Obtaining a post-voided residual (PVR) volume requires a specific clinical skill and understanding of the procedure, which should be performed by a licensed nurse rather than a UAP.
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