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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bringing the client to sit at the nursing station may not address the underlying cause of the wandering behavior and could be less effective in meeting the client’s immediate needs.
B. Administering a nighttime sedative is not a suitable solution for wandering behavior, as it may lead to adverse effects and does not address the root cause of the behavior.
C. Directing the client to go back to bed may not be effective, especially if the client is disoriented or confused. The approach should involve understanding and addressing the client's needs.
D. Engaging the client to determine current needs is the best approach, as it helps to understand the cause of the wandering and address it appropriately, such as providing comfort, reassurance, or addressing a specific need.
Correct Answer is B
Explanation
A. Wearing gloves during breakfast service is not always required, and the focus should be on ensuring proper hand hygiene rather than glove use.
B. The hand rub should be completed in 20-30 seconds, and the UAP’s 2-minute hand rub is excessive. Proper hand hygiene techniques should be reinforced.
C. The UAP does not need to remain in the client's room during hand hygiene; the primary issue is the duration of the hand rub.
D. Inspecting the hands for cleanliness is not necessary if the hand hygiene practice is incorrect; instead, correcting the technique is more important.
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