A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is most appropriate?
Give the client a bottle of water immediately.
Perform an electrocardiogram.
Teach the patient to drink 2 to 3 L of water daily.
Start an intravenous line for fluids.
The Correct Answer is D
Rationale:
A. While the client is likely dehydrated, giving a bottle of water orally may be too slow or insufficient to restore circulating volume, especially if the client is hypotensive and tachycardic.
B. An electrocardiogram (ECG) may be useful later to assess for cardiac effects of dehydration or electrolyte imbalance, but it does not address the immediate hypovolemia.
C. Teaching about daily fluid intake is preventive education and not appropriate for the acute, potentially life-threatening situation.
D. The client shows signs of hypovolemic shock: tachycardia, hypotension, and oliguria. The priority is to rapidly restore intravascular volume with an intravenous (IV) fluid bolus to improve perfusion and prevent kidney injury or other organ damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. The kidneys do not transport red blood cells; the circulatory system does. This option confuses renal function with circulatory processes.
B. Red blood cells do not produce erythropoietin; rather, the kidneys produce erythropoietin to stimulate red blood cell formation in the bone marrow.
C. While vitamin D metabolism and bone density are affected by kidney disease, these are not the primary cause of anemia in renal insufficiency.
D. The kidneys produce erythropoietin, a hormone that stimulates red blood cell production in the bone marrow. In renal insufficiency, reduced erythropoietin secretion leads to anemia due to decreased red blood cell formation.
Correct Answer is ["A","C","E"]
Explanation
Rationale:
A. Clients with end-stage kidney disease (ESKD) must restrict foods high in potassium, sodium, and phosphorus to prevent electrolyte imbalances, fluid overload, and bone-mineral disorders. Dietary restrictions can significantly affect quality of life because they limit many common foods (e.g., bananas, dairy, tomatoes, processed foods).
B. Airplane travel is not restricted for clients receiving hemodialysis. Travel can be arranged around treatment schedules or coordinated with dialysis centers in other locations.
C. Fluid restriction is necessary to prevent fluid overload, hypertension, and pulmonary edema. Limiting fluids can be physically and emotionally challenging, often affecting comfort and daily routines.
D. Driving restrictions are not routinely required for hemodialysis clients unless other conditions (e.g., severe fatigue, hypotension post-dialysis, or cognitive impairment) interfere with safe driving.
E. Time constraints are a major quality-of-life issue because hemodialysis typically requires treatments three times per week, lasting 3–5 hours per session. This limits flexibility for work, social life, and travel.
F. Clients do not need to limit social activities to a set frequency; participation is encouraged as tolerated and helps maintain psychological well-being.
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