An 85-year-old patient who has fallen at home and was unable to get up is admitted to your nursing unit. The patient said she fell 36 hours ago and has been unable to eat or drink. You observe that the patient has voided scant amounts since admission. In planning care for this patient, what condition do you consider related to the diminished renal output?
Renal calculi
Hypovolemia
inactivity
Nephrotoxic drugs
The Correct Answer is B
A. While renal calculi (kidney stones) can cause renal issues, they are not directly related to diminished renal output in this scenario. Hypovolemia, or low blood volume, is more pertinent to the patient's presentation of scant voiding and inability to eat or drink.
B. Diminished renal output, as evidenced by scant voiding, can be indicative of hypovolemia. Hypovolemia reduces kidney perfusion, leading to decreased urine output as the kidneys conserve fluid.
C. While inactivity can contribute to various health issues, it's not directly related to diminished renal output in this case. The primary concern is addressing the immediate physiological impact of decreased renal function.
D. While nephrotoxic drugs can impair renal function, there's no indication in the scenario that the patient has been exposed to such drugs. Thus, they are not directly relevant to the current situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Jaundice is typically not visible in the webbed areas of the fingers.
B. The nail beds are part of the skin that can show jaundice, but they may also be affected by other factors such as anemia, cyanosis, or nail polish.
C. The hard palate is a part of the oral mucosa that can show jaundice, especially in clients with dark skin tones.
D. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The skin can show jaundice, but it may be difficult to detect in clients with dark skin tones.
Correct Answer is D
Explanation
A. While draping is essential for maintaining sterility, it's typically done right before the physician performs the biopsy, not as a primary pre-procedure step for the nurse.
B. Monitoring for bleeding is important after the procedure, not necessarily beforehand.
C. Although informing the family can be helpful, the patient's understanding and consent are the top priority. Pain management is crucial for patient comfort and cooperation during the procedure.
D. Administering an analgesic helps reduce the patient's anxiety and discomfort during the bone marrow biopsy, which can be a painful procedure. This improves patient tolerance and allows the physician to perform the procedure more efficiently.
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