The client has been admitted to the hospital with a diagnosis of acute kidney injury (AKI).
Which of the following is a priority nursing intervention?
Administer pain medication.
Monitor urine output.
Encourage ambulation.
Assist with meals.
The Correct Answer is B
This is a priority nursing intervention for a client with acute kidney injury (AKI) because it helps to assess the renal function and fluid status of the client. Urine output is also an indicator of the response to treatment and the need for further interventions.
Choice A is wrong because pain medication is not a priority intervention for AKI unless the client has other conditions that cause pain.
Pain medication may also have adverse effects on the kidney function and should be used with caution.
Choice C is wrong because ambulation is not a priority intervention for AKI and may not be appropriate for a client who is fluid overloaded or hypotensive.
Ambulation may also increase the risk of falls and injury in a client who is confused or fatigued.
Choice D is wrong because assisting with meals is not a priority intervention for AKI and may not be necessary for a client who has adequate oral intake.
A client with AKI may also have dietary restrictions such as low protein, low potassium, low sodium, and low phosphorus, which should be considered when providing meals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because urinary catheters are a common source of catheter associated urinary tract infections (CAUTIs), which can lead to complications such as pyelonephritis, sepsis, and renal failure. Therefore, the nurse should remove the catheter as soon as possible to reduce the risk of infection and promote normal urinary function.
Choice B is wrong because ensuring that the catheter is properly secured to prevent accidental dislodgement is not a priority intervention for a patient with a urinary catheter.
While this is an important nursing action to prevent trauma and bleeding, it does not address the main complication of catheterization, which is infection.
Choice C is wrong because encouraging the patient to drink fluids to prevent dehydration is not a priority intervention for a patient with a urinary catheter.
While this is a good nursing practice to maintain hydration and renal perfusion, it does not affect the risk of infection associated with catheterization.
Choice D is wrong because administering antibiotics to prevent infection is not a priority intervention for a patient with a urinary catheter.
While this may be indicated for some patients who have signs and symptoms of UTI or who are at high risk of infection, it is not a routine measure for all patients with catheters and may contribute to antibiotic resistance.
Correct Answer is A
Explanation
Fluid overload, also called hypervolemia, is a condition in which the body has too much water.
It can cause edema, hypertension, shortness of breath, and cardiovascular problems.
Diuretics are medications that help the body remove excess fluid through urine.
They are commonly used to treat fluid overload caused by heart failure, kidney failure, cirrhosis, and other conditions.
Choice B is wrong because encouraging increased fluid intake would worsen the fluid overload and increase the risk of complications.
Choice C is wrong because providing a high-sodium diet would also worsen the fluid overload and increase the risk of complications.
Sodium is an electrolyte that regulates fluid balance in the body.
Excess sodium intake can cause water retention and increase blood pressure.
Choice D is wrong because elevating the affected extremities is not an appropriate intervention for fluid overload.
Elevating the extremities can help reduce swelling caused by local factors such as injury or inflammation, but it does not address the underlying cause of fluid overload.
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