A patient with acute renal failure (ARF) is admitted due to uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale.
What is the most important intervention for the nurse to include in this patient’s plan of care?

Monitor the patient’s cardiac activity via telemetry.

Assess glucose via fingerstick every 4 to 6 hours.

Evaluate hourly urine output for return of normal renal function.

Maintain venous access with an infusion of normal saline.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Monitoring the patient’s cardiac activity via telemetry is the most important intervention for a patient with acute renal failure (ARF), uncontrolled type 1 diabetes mellitus, and hyperkalemia who is receiving an IV dose of regular insulin. Hyperkalemia can cause cardiac arrhythmias and other cardiac complications. Therefore, continuous cardiac monitoring is crucial to detect any changes in heart rhythm or rate that could indicate worsening hyperkalemia.
Choice B rationale
While assessing glucose via fingerstick every 4 to 6 hours is important for a patient with uncontrolled type 1 diabetes mellitus, it is not the most important intervention in this scenario. The patient’s hyperkalemia and ARF pose more immediate risks.
Choice C rationale
Evaluating hourly urine output for return of normal renal function is an important part of monitoring a patient with ARF34. However, in the context of hyperkalemia and the administration of insulin, cardiac monitoring is more critical.
Choice D rationale
Maintaining venous access with an infusion of normal saline is a standard nursing intervention for most hospitalized patients, but it is not the most important intervention in this scenario.

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}

Explanation

Choice A rationale
Administering IV fluids is a potential nursing intervention for several body systems. For example, the circulatory system may require IV fluids to maintain blood volume and pressure. The renal system may need IV fluids to ensure adequate urine output. The digestive system might need IV fluids to compensate for losses from vomiting or diarrhea.
Choice B rationale
Assessing a rash is a potential nursing intervention for the integumentary system. Rashes can be a sign of many different conditions, including allergic reactions, infections, autoimmune diseases, and more. By assessing the rash, the nurse can gather information to help determine its cause and appropriate treatment.
Choice C rationale
Administering an antihistamine is a potential nursing intervention for the immune system. Antihistamines are often used to treat allergic reactions, which involve the immune system.

They can also be used to treat symptoms of the common cold, which is caused by a viral infection.
Choice D rationale
Administering a steroid is a potential nursing intervention for several body systems. Steroids can be used to reduce inflammation, which can benefit the musculoskeletal, integumentary, respiratory, and other systems. They can also be used to treat certain endocrine disorders.

A. Ask the UAP to take the blood pressure in the other arm. B. Tell the UAP to use a different sphygmomanometer. C. Review the client’s serum calcium level. D. Administer a PRN antianxiety medication.

Correct Answer is C

Explanation

Choice A rationale
While taking the blood pressure in the other arm might avoid the spasms, it does not address the underlying cause of the spasms. Therefore, this is not the best action for the nurse to take.
Choice B rationale

Using a different sphygmomanometer would not necessarily prevent the spasms from occurring. The spasms are likely not caused by the equipment itself, but rather a physiological issue within the client.
Choice C rationale
The spasms in the client’s hand and fingers could be a sign of hypocalcemia, a condition where there is not enough calcium in the blood. One of the symptoms of hypocalcemia is muscle spasms or tetany. Therefore, reviewing the client’s serum calcium level would be an appropriate action to take.
Choice D rationale
Administering a PRN antianxiety medication would not address the underlying cause of the spasms. While anxiety can cause muscle tension and spasms, there is no indication in the scenario that anxiety is the cause of this client’s symptoms.

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A patient with acute renal failure (ARF) is admitted due to uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. What is the most important intervention for the nurse to include in this patient’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}

Explanation

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Correct Answer is C

Explanation

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A patient with acute renal failure (ARF) is admitted due to uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale.
What is the most important intervention for the nurse to include in this patient’s plan of care?