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A patient is admitted with acute kidney injury and the following assessment cues:

K: 6.9 (3.5-5.0)

Cr: 3.2 (0.6-1.2)

Urine: 300 mL/24 hrs

What priority actions should be anticipated by the nurse? Select all that apply.

Place the patient on a cardiac monitor immediately.

Weigh the patient immediately.

Anticipate a fluid bolus.

Ask to have the laboratory redraw the blood specimen.

Anticipate an order for a diuretic.

Prepare to administer IV insulin and dextrose as ordered.

Administer Kayexalate (sodium polystyrene) as ordered.

Answer and Explanation

Correct Answer : A

Choice A reason: Placing the patient on a cardiac monitor immediately is crucial due to the elevated potassium level (6.9), which can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and prompt management of any arrhythmias that may occur.

Choice B reason: Weighing the patient immediately is important for assessing fluid status and for calculating appropriate medication dosages. In patients with acute kidney injury, monitoring fluid balance is critical to prevent fluid overload and ensure accurate treatment.

Choice C reason: Anticipating a fluid bolus is not appropriate for this patient. Fluid overload can exacerbate kidney injury and worsen the patient's condition. Fluid management should be carefully tailored based on the patient's overall clinical status and needs.

Choice D reason: Asking to have the laboratory redraw the blood specimen is unnecessary if the initial results are accurate and timely. The focus should be on addressing the critical findings, such as hyperkalemia, rather than retesting.

Choice E reason: Anticipating an order for a diuretic might be considered, but it is not the immediate priority. Diuretics may be useful in managing fluid overload but do not directly address the immediate life-threatening hyperkalemia.

Choice F reason: Preparing to administer IV insulin and dextrose as ordered is essential for treating hyperkalemia. Insulin helps to shift potassium into cells, thereby lowering the serum potassium level. Dextrose is given concurrently to prevent hypoglycemia caused by insulin administration.

Choice G reason: Administering Kayexalate (sodium polystyrene) as ordered is important for removing excess potassium from the body. Kayexalate works by exchanging sodium for potassium in the intestines, promoting the excretion of potassium in the stool.

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Correct Answer is A

Explanation

Choice A reason: Obtaining daily weights of the client is the best action to assess the therapeutic effect of furosemide in managing early chronic kidney disease. Daily weights provide valuable information about fluid balance and the effectiveness of the diuretic in reducing fluid retention. Consistent weight monitoring helps determine if the medication is achieving its goal of managing fluid overload, which is a common issue in CKD patients.

Choice B reason: Assessing acid-base balance is important in managing CKD, but it is not the primary action to assess the therapeutic effect of furosemide. While diuretics can influence electrolyte levels and acid-base balance, monitoring fluid status through daily weights is more directly related to evaluating the effectiveness of the medication.

Choice C reason: Assessing the client's serum creatinine is crucial for monitoring kidney function and progression of CKD. However, it is not the primary action to determine the therapeutic effect of furosemide. The focus of furosemide therapy is to manage fluid balance, and daily weights provide a more immediate and relevant assessment of this effect.

Choice D reason: Auscultating heart sounds is part of a comprehensive assessment of a CKD patient, but it is not the best action to evaluate the therapeutic effect of furosemide. Heart sounds can provide information about cardiac function and potential complications, but they do not directly measure the effectiveness of fluid management achieved by the diuretic.

A. Pulmonary embolism B. Left-sided heart failure C. Early onset dementia D. Acute myocardial infarction

Correct Answer is A

Explanation

Choice A reason: Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body. The signs and symptoms include sudden shortness of breath, rapid breathing (tachypnea), rapid heart rate (tachycardia), and anxiety. These symptoms align with the patient's presentation and are common in the post-operative period, particularly after orthopedic surgery, which increases the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism.

Choice B reason: Left-sided heart failure can cause symptoms such as shortness of breath, fatigue, and fluid retention. However, the acute presentation of difficulty breathing, tachypnea, tachycardia, and anxiety in the context of recent surgery is more suggestive of a pulmonary embolism. Heart failure symptoms generally develop gradually rather than suddenly.

Choice C reason: Early onset dementia is not characterized by acute respiratory symptoms like difficulty breathing, tachypnea, or tachycardia. Dementia symptoms typically include memory loss, confusion, and changes in cognitive function, not the acute cardiorespiratory symptoms described in this scenario.

Choice D reason: Acute myocardial infarction (heart attack) can cause shortness of breath, chest pain, and rapid heart rate. While it is a possibility, the combination of recent surgery and the described symptoms more strongly suggests a pulmonary embolism. An acute myocardial infarction would typically also present with chest pain, which is not mentioned in this scenario.

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A patient is admitted with acute kidney injury and the following assessment cues: K: 6.9 (3.5-5.0) Cr: 3.2 (0.6-1.2) Urine: 300 mL/24 hrs What priority actions should be anticipated by the nurse? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A client is taking furosemide 40 mg/day for management of early chronic kidney disease (CKD). To assess the therapeutic effect of the medication, what action of the nurse is best?

Correct Answer is A

Explanation

A 76-year-old patient is 2 days post-op total hip replacement. The patient puts his call light on to complain of difficulty catching his breath. As the nurse assesses the patient, she finds the patient tachypneic, tachycardic, and very anxious. The nurse determines these are most likely signs of:

Correct Answer is A

Explanation

A patient is admitted with acute kidney injury and the following assessment cues: K: 6.9 (3.5-5.0) Cr: 3.2 (0.6-1.2) Urine: 300 mL/24 hrs What priority actions should be anticipated by the nurse? Select all that apply.

A patient who is in hypovolemic shock has the following clinical signs: BP 80/55 mmHg, heart rate 120 beats/min, and urine output of 20 mL/hr. After administering an IV fluid bolus, which of these signs is the best indication of improved perfusion?

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The nurse is caring for a patient in shock with disseminated intravascular coagulation (DIC) and would expect to see the following assessments: petechiae, bleeding gums, and

A patient is admitted with acute kidney injury and the following assessment cues:

K: 6.9 (3.5-5.0)

Cr: 3.2 (0.6-1.2)

Urine: 300 mL/24 hrs

What priority actions should be anticipated by the nurse? Select all that apply.