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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: Decerebrate posturing is characterized by the extension of the arms and legs, pronation of the arms, and plantar flexion. This type of posturing indicates severe brain damage, typically involving the brainstem. It is a sign of a more serious injury than decorticate posturing and suggests that the damage has progressed to affect the brainstem.

Choice B reason: Flexion withdrawal is a response to a painful stimulus where the patient pulls away from the pain. It is a reflex that indicates some level of preserved spinal cord or brainstem function. However, it does not involve the specific pattern of extension and pronation seen in decerebrate posturing.

Choice C reason: Decorticate posturing involves flexion of the arms, clenched fists, and extension of the legs. The arms are bent inward toward the body with the wrists and fingers flexed on the chest. This posturing indicates damage to the brain's cortical areas or the corticospinal tract. It is less severe than decerebrate posturing.

Choice D reason: Localization of pain is a response where the patient moves a hand towards the site of the painful stimulus, indicating a higher level of brain function. This response suggests that the brain can still process and respond to the location of the pain, which is not consistent with the described posturing.

A. Maintain nothing by mouth (NPO) and administer intravenous fluids. B. Provide small, frequent feedings with no concentrated sweets. C. Administer morphine sulfate intramuscularly every 4 hours as needed. D. Position the patient in a flat, supine position to decrease discomfort.

Correct Answer is A

Explanation

Choice A reason: Maintaining nothing by mouth (NPO) and administering intravenous fluids is the best intervention to reduce discomfort in a patient with acute pancreatitis. NPO status helps to rest the pancreas by preventing the secretion of pancreatic enzymes that can exacerbate inflammation and pain. Intravenous fluids are essential to maintain hydration and electrolyte balance while the patient is not eating or drinking.

Choice B reason: Providing small, frequent feedings with no concentrated sweets is not appropriate for a patient with acute pancreatitis. The priority is to keep the patient NPO to rest the pancreas. Introducing any food can stimulate the pancreas and worsen the condition.

Choice C reason: Administering morphine sulfate intramuscularly every 4 hours as needed can help manage pain, but the preferred route for pain medication in acute pancreatitis is intravenous, as it provides quicker relief and avoids the discomfort of intramuscular injections. Pain management is important, but it should be part of a broader plan that includes NPO status and IV fluids.

Choice D reason: Positioning the patient in a flat, supine position is not recommended for reducing discomfort in acute pancreatitis. Patients often find relief in a semi-Fowler's position (head elevated) or by leaning forward, which can help reduce abdominal pain and pressure on the inflamed pancreas.

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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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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.