A nurse in a provider’s office is caring for a 68-year-old male client who reports changes in activity tolerance, feeling tired all the time, and difficulty remembering things. The client also states they bruise easily.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, what actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Condition: The client is most likely experiencing B. Acute Renal Failure. This is suggested by the client’s reported anuria (absence of urine), erythema around the arteriovenous fistula (AVF) site, and the CT scan showing distention with fluid and gas in the small intestine.
Action: The nurse should take the following actions to address this condition:
- A. Administer IV fluids as prescribed: This can help manage the client’s hydration and electrolyte balance.
- E. Administer pain medication as prescribed: This can help manage any discomfort the client may be experiencing.
Parameter: The nurse should monitor the following parameters to assess the client’s progress:
- A. Monitor blood pressure: Monitoring blood pressure is crucial in patients with acute renal failure as both hypotension and hypertension can occur.
- E. Monitor urine output: This is a key indicator of kidney function and should be closely monitored. Changes in urine output can provide early signs of improvement or deterioration in the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While an antiemetic might help with the vomiting, it would not address the underlying issue of not having a bowel movement for 4 days. Therefore, this choice is incorrect.
Choice B rationale
If the client has a nasogastric tube, checking its position would be a good first step. If the tube is not in the correct position, it could be causing or contributing to the client’s symptoms.
Therefore, this choice is correct.
Choice C rationale
Increasing the suction on a nasogastric tube might help if the tube is functioning correctly and the problem is related to stomach contents not being properly evacuated. However, it would not be the first step before checking the position of the tube. Therefore, this choice is incorrect.
Choice D rationale
Repositioning the nasogastric tube might be necessary if it’s not in the correct position, but this would not be the first step before checking its position. Therefore, this choice is incorrect.
Correct Answer is A
Explanation
Choice A rationale
Glaucoma is a contraindication for taking propranolol. Propranolol is a non-selective beta- blocker that can decrease intraocular pressure, which could worsen glaucoma.
Choice B rationale
DeBou syndrome is not a recognized medical condition and therefore cannot be a contraindication for taking propranolol.
Choice C rationale
Migraine headaches are not a contraindication for taking propranolol. In fact, propranolol is often used in the prevention of migraines.
Choice D rationale
A history of kidney stones is not a contraindication for taking propranolol. Propranolol does not affect kidney stone formation or exacerbate this condition.
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