A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in this client's plan of care?

Maintain venous access with an infusion of normal saline.

Assess glucose via fingerstick every 4 to 6 hours.

Evaluate hourly urine output for return of normal renal function.

Monitor the client's cardiac activity via telemetry.

Answer and Explanation

The Correct Answer is D

A. Maintain venous access with an infusion of normal saline: While maintaining venous access is important, it is not the most critical intervention in managing hyperkalemia and insulin therapy.
B. Assess glucose via fingerstick every 4 to 6 hours: Regular monitoring of blood glucose is important, but the most immediate concern in hyperkalemia management with insulin is the cardiac effects.
C. Evaluate hourly urine output for return of normal renal function: This is important for overall renal function assessment but is less critical during the acute management of hyperkalemia.
D. Monitor the client's cardiac activity via telemetry: Insulin can cause a shift of potassium into cells, which can lead to changes in cardiac function. Therefore, monitoring cardiac activity is crucial to detect any potential arrhythmias due to changes in potassium levels.

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Correct Answer is ["B","C","E"]

Explanation

A. Using standard precautions and wearing a mask are generally used for preventing the spread of infections but are not specific to VRE, which requires contact precautions.
B. Monitoring the client's white blood cell count is important for assessing the severity of the infection and the body’s response to it, which is crucial for ongoing management.
C. Sending wound drainage for culture and sensitivity is essential for identifying the causative pathogen and determining the most effective treatment, especially given the suspected VRE infection.
D. A low bacteria diet is more relevant for immunocompromised clients or those undergoing specific treatments, and it is not a primary intervention for managing VRE.
E. Instituting contact precautions for staff and visitors is necessary to prevent the spread of VRE, as VRE is transmitted through direct or indirect contact.

A. Encourage the parents to allow the child to continue attending swimming lessons with supervision. B. Provide a list of alternative activities that are less likely to cause the child to experience fatigue. C. Explain that their child is too young to understand the risks associated with swimming. D. Suggest that the child be encouraged to participate in a team sport to encourage socialization.

Correct Answer is A

Explanation

A. Encourage the parents to allow the child to continue attending swimming lessons with supervision: Swimming is a low-impact exercise that can be beneficial for children with Duchenne muscular dystrophy, and supervision ensures safety.
B. Provide a list of alternative activities that are less likely to cause the child to experience fatigue: While considering fatigue is important, swimming can be a safe and beneficial activity if supervised.
C. Explain that their child is too young to understand the risks associated with swimming: The child's age is not a relevant factor; safety measures and supervision are key.
D. Suggest that the child be encouraged to participate in a team sport to encourage socialization: Team sports are not necessarily appropriate for a child with Duchenne muscular dystrophy due to potential physical strain.

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A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in this client's plan of care?

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Naxlex Comprehensive Predictor Exams

A client with purulent discharge from a venous ulcer that has been unsuccessfully treated with intravenous vancomycin has been admitted with a possible vancomycin-resistant enterococci (VRE) infection. What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

Correct Answer is A

Explanation

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