A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?
Place the patient on a cardiac monitor.
Insert a urinary retention catheter.
Give the prescribed spironolactone.
Administer epoetin alfa (Epogen).
The Correct Answer is A
Choice A rationale
In the case of hyperkalemia, which can cause fatal cardiac arrhythmias, the most immediate nursing action is to place the patient on a cardiac monitor. This allows for continuous monitoring of the heart's rhythm and immediate detection of any life-threatening changes, which is crucial for timely intervention.
Choice B rationale
Inserting a urinary retention catheter may be necessary for managing oliguria, but it is not the most urgent action when compared to the potential cardiac risks associated with hyperkalemia.
Choice C rationale
Administering spironolactone, a potassium-sparing diuretic, could be part of the treatment for hyperkalemia, but it is not the first action to take. Spironolactone works more slowly and does not address the immediate risk of cardiac arrhythmias.
Choice D rationale
Epoetin alfa (Epogen) is used to treat anemia, particularly in chronic kidney disease, to increase red blood cell production. However, it does not have an immediate effect and is not the priority in the presence of hyperkalemia and potential cardiac complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Canned soup is typically high in sodium, which can worsen fluid volume excess (FVE). Patients with liver failure need to limit sodium intake to reduce fluid retention.
Choice B rationale
Baked chicken breast is a low-sodium and protein-rich option suitable for clients with liver failure. Protein is essential for tissue repair and maintaining fluid balance within the body.
Choice C rationale
A bowl of ice cream is high in sugar and fat, which can be difficult for a liver-compromised patient to process and may contribute to further fluid retention.
Choice D rationale
Spaghetti with commercial red sauce can be high in sodium due to the sauce, which is not recommended for clients with FVE as it may exacerbate their condition.
Correct Answer is ["B","C","E","F"]
Explanation
Choice A rationale
Hypertension is not a typical manifestation of pyelonephritis. While it can be present due to other underlying conditions, it is not directly related to pyelonephritis.
Choice B rationale
Frequency, or the need to urinate more often, is a common symptom of pyelonephritis as the infection can irritate the bladder and urinary tract.
Choice C rationale
Flank pain is a classic symptom of pyelonephritis. It is usually located on the side of the affected kidney and can be quite severe.
Choice D rationale
Neck pain is not associated with pyelonephritis. It is more likely related to musculoskeletal issues or other non-urinary tract conditions.
Choice E rationale
Costovertebral tenderness, which is tenderness felt on tapping the back where the ribs meet the spine, is indicative of kidney infection and is expected in pyelonephritis.
Choice F rationale
Urgency, or a sudden, strong need to urinate, is another symptom of pyelonephritis due to inflammation and irritation in the urinary system.
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