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Exhibits

Use an X for the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the patient's care at this time. Only one selection can be made for each nursing action.

A.

Assess for the presence of bowel sounds every 4 hours

B.

Medicate with ibuprofen every 6 hours as needed for complaint of pain.

C.

Carefully consider the type, frequency, and dosage of the patient's prescribed antibiotic therapy.

D.

Focus on providing holistic nursing care to patient.

E.

Obtain daily weights.

F.

Consult with dietician to provide a low caloric diet.

Answer and Explanation

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

  • Assessing for bowel sounds every 4 hours is nonessential in this case since the patient’s primary problem is pyelonephritis with acute kidney injury. Bowel sounds are not directly affected by this condition, so frequent monitoring adds little benefit to her care at this time.
  • Administering ibuprofen is contraindicated because NSAIDs reduce renal blood flow by inhibiting prostaglandins, which can worsen acute kidney injury. Alternative pain control methods should be used to avoid further kidney damage.
  • Carefully considering the type, frequency, and dosage of antibiotics is indicated because impaired kidney function affects drug metabolism and clearance. Adjusting antibiotic therapy prevents drug accumulation and ensures effectiveness against the infection.
  • Focusing on holistic nursing care is indicated since the patient is disoriented, anxious, and has her daughter present. Addressing emotional, psychological, and family support needs promotes overall well-being alongside medical management.
  • Obtaining daily weights is indicated because weight changes reflect fluid retention or loss, which is critical in monitoring renal function and guiding fluid management in acute kidney injury.
  • Consulting with a dietician for a low caloric diet is nonessential because the primary nutritional focus in kidney injury is adjusting protein, electrolytes, and fluid intake rather than caloric restriction. A low-calorie diet could even be harmful if it impairs recovery.


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Related Questions

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

Explanation

  • Administering NSAIDs for pain relief is contraindicated because NSAIDs can further impair kidney function by reducing renal perfusion and promoting nephrotoxicity. In a client with elevated BUN and creatinine, these drugs can accelerate kidney injury and worsen fluid retention or hypertension.
  • Encouraging a high-protein diet is contraindicated in this scenario. Excess protein intake increases the workload on the kidneys and can exacerbate azotemia in clients with chronic kidney disease, particularly when BUN and creatinine are already elevated.
  • Assessing for signs of fluid overload is an anticipated nursing action. The client presents with edema, periorbital swelling, and decreased urine output, indicating fluid retention. Monitoring for increased edema, lung sounds, weight gain, and blood pressure helps prevent complications such as pulmonary edema or worsening hypertension.
  • Monitoring blood glucose levels regularly is an anticipated nursing action because diabetes contributes to kidney damage and can complicate the management of chronic kidney disease. Maintaining optimal glucose control reduces further renal injury and helps prevent acute complications such as hyperglycemia-related fluid shifts.

Correct Answer is B

Explanation

A. Hematuria: The presence of blood in the urine is expected for the first few days after extracorporeal shock wave lithotripsy. It results from trauma to the urinary tract and usually resolves on its own, so it does not require urgent reporting unless it becomes severe or prolonged.

B. Oliguria: Decreased urine output is the most concerning finding because it may indicate obstruction from stone fragments or acute kidney injury. This complication can quickly compromise renal function and requires immediate evaluation by the healthcare provider.

C. Ecchymosis in left flank: Bruising around the flank is a common side effect of the shock waves used during lithotripsy. While it may be uncomfortable, it is not considered dangerous and does not require urgent intervention.

D. Left flank discomfort: Pain is expected after the procedure due to both the passage of stone fragments and localized tissue trauma. Analgesics are typically used to manage this symptom, and it is not considered a critical finding to report.

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