A nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?
Reports of a bad taste in the mouth.
Low concentrated urine output.
Dyspnea and sinus tachycardia.
Productive cough and fever.
The Correct Answer is C
Choice A reason: Reports of a bad taste in the mouth can be associated with various conditions, including metabolic imbalances, but it is not typically an immediate concern in the context of AKI.
Choice B reason: Low concentrated urine output (oliguria) is a common finding in AKI and indicates decreased kidney function. While it is an important assessment finding, it does not usually require immediate intervention compared to signs of severe complications.
Choice C reason: Dyspnea (difficulty breathing) and sinus tachycardia (rapid heart rate) can indicate fluid overload or pulmonary edema, which are serious complications of AKI. These symptoms require immediate intervention to prevent respiratory distress and potential cardiac complications.
Choice D reason: A productive cough and fever may suggest an infection, which is important to address but not necessarily an immediate life-threatening issue compared to dyspnea and tachycardia in the context of AKI.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: An old friend with eczema coming for a visit is unlikely to cause an exacerbation of the client's symptoms. Eczema is not contagious, so contact with another person who has eczema should not worsen the condition. This choice does not provide useful information about potential triggers for the eczema flare-up.
Choice B reason: Receiving an influenza immunization is generally safe for individuals with eczema and is unlikely to cause an exacerbation of symptoms. Vaccinations do not typically provoke eczema flare-ups. This choice does not offer relevant information regarding potential causes of the worsening eczema symptoms.
Choice C reason: The application of corticosteroid cream to eczema is a common treatment to reduce inflammation and alleviate symptoms. It is unlikely to cause an exacerbation of eczema; in fact, it should help improve the condition. This choice does not explain the recent worsening of the eczema.
Choice D reason: A recent visit from a grandson and his new dog is a plausible trigger for an eczema flare-up. Pets, particularly new ones, can introduce allergens such as pet dander and saliva, which can aggravate eczema. This choice provides the most relevant information for determining the potential cause of the exacerbation.
Correct Answer is B
Explanation
Choice A reason: Administering a PRN dose of an antispasmodic agent can help relieve bladder spasms that often occur after TURP, but it does not address the immediate issue of blood clots blocking the drainage tubing. The primary concern is to ensure the patency of the catheter and proper drainage.
Choice B reason: Increasing the flow of the bladder irrigation is the best initial action. By increasing the flow, the nurse can help flush out the blood clots from the drainage tubing and ensure that the catheter remains patent. This action directly addresses the problem of blocked drainage and prevents further complications.
Choice C reason: Measuring the client's intake and output is important for overall monitoring, but it does not directly address the immediate concern of blood clots in the drainage tubing. Ensuring proper drainage is crucial to prevent complications such as bladder distention and further bleeding.
Choice D reason: Providing additional oral fluid intake is beneficial for maintaining hydration and promoting urine output, but it does not solve the problem of blood clots in the drainage tubing. The primary focus should be on ensuring the catheter's patency through irrigation.
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