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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Avoiding straining while having a bowel movement is important for patients with a low heart rate. Straining can stimulate the vagus nerve, which can lead to further bradycardia (slowing of the heart rate). By avoiding straining, patients can prevent additional vagal stimulation and help maintain a stable heart rate.
Choice B reason: Limiting the intake of caffeinated drinks to one a day is not directly related to avoiding further slowing of the heart rate. While excessive caffeine can have effects on heart rhythm and overall cardiovascular health, moderate caffeine intake is not typically associated with a significant risk of bradycardia.
Choice C reason: Ensuring that bath water is warm is not directly related to preventing further slowing of the heart rate. While warm water can promote relaxation and comfort, it does not have a direct impact on heart rate management for individuals with bradycardia.
Choice D reason: Modifying strenuous exercise such as running is a good general recommendation for individuals with heart conditions, but it is not specifically targeted at preventing further bradycardia. Exercise modification is more relevant for managing overall cardiovascular health and preventing tachycardia (increased heart rate).
Correct Answer is B
Explanation
Choice A reason: Inotropic drugs are used to improve the strength of the heart's contractions and support cardiac output in cases of heart failure or cardiogenic shock. While they may be used as supportive therapy in septic shock to maintain blood pressure and perfusion, they are not the primary treatment.
Choice B reason: Antibiotics are the primary and most crucial therapy for managing septic shock. Septic shock is caused by a severe infection that leads to systemic inflammation and organ dysfunction. Prompt administration of broad-spectrum antibiotics is essential to target the underlying infection and prevent the progression of septic shock. Antibiotic therapy is initiated as soon as possible, often after obtaining blood cultures to identify the causative pathogen.
Choice C reason: Antidysrhythmic drugs are used to manage abnormal heart rhythms, such as atrial fibrillation or ventricular tachycardia. They are not specific to the treatment of septic shock but may be used if the patient develops arrhythmias as a complication of the shock state.
Choice D reason: Beta blockers are used to manage hypertension and certain types of arrhythmias by reducing the heart rate and the workload on the heart. They are not typically used in the acute management of septic shock and may even be contraindicated due to their potential to decrease cardiac output.
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