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 ["A","C","E"]
Explanation
Choice A rationale
Monitoring fluid and electrolytes is essential in managing ascites to prevent complications such as fluid overload or electrolyte imbalances, which can exacerbate the condition.
Choice B rationale
Providing a high-sodium diet is not recommended for patients with ascites. Sodium restriction is typically advised to help manage fluid retention.
Choice C rationale
Anticipating paracentesis is appropriate as it is a procedure used to remove excess fluid from the abdominal cavity, providing relief from discomfort and respiratory difficulty.
Choice D rationale
Encouraging high-fluid intake is not recommended for ascites management. Fluid restriction may be necessary to prevent further accumulation of fluid in the abdominal cavity.
Choice E rationale
Administering an albumin infusion can be part of the treatment for ascites, especially following paracentesis, to help maintain blood volume and pressure.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Hypertension is a modifiable risk factor for atherosclerosis. Managing blood pressure through lifestyle changes and medication can reduce the risk of developing atherosclerosis.
Choice B rationale
Hypercholesterolemia, or high cholesterol, is another modifiable risk factor. Dietary adjustments, physical activity, and medications can help manage cholesterol levels.
Choice C rationale
Genetic predisposition is not a modifiable risk factor. It is an inherent risk that cannot be changed, but awareness can prompt early monitoring and intervention.
Choice D rationale
Obesity is a modifiable risk factor for atherosclerosis. Weight loss through diet and exercise can significantly reduce the risk.
Choice E rationale
Smoking is a significant modifiable risk factor for atherosclerosis. Quitting smoking can greatly reduce the risk of developing this condition.
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