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 D
Explanation
Furosemide is a diuretic that lowers blood pressure by increasing urine output and reducing fluid volume in the body.
One of the possible adverse effects of furosemide is hypotension, which is low blood pressure.
This can cause symptoms such as dizziness, faintness, confusion, or weakness.
The nurse should monitor the client’s blood pressure and report any signs of hypotension to the doctor.
Choice A is wrong because hypertension, which is high blood pressure, is not a common side effect of furosemide.
In fact, furosemide is used to treat hypertension in some cases.
Choice B is wrong because hypoglycemia, which is low blood sugar, is not a common side effect of furosemide.
Furosemide does not affect blood sugar levels directly.
However, it may interact with some medications that lower blood sugar, such as insulin or oral antidiabetic drugs.
The nurse should check the client’s medication history and monitor their blood sugar levels if they are taking any of these drugs.
Choice C is wrong because hyperkalemia, which is high potassium levels in the blood, is not a common side effect of furosemide.
Furosemide belongs to a class of diuretics called loop diuretics, which lower potassium levels by increasing its excretion in the urine.
One of the possible adverse effects of furosemide is hypokalemia, which is low potassium levels in the blood.
This can cause symptoms such as muscle cramps, weakness, irregular heartbeat, or numbness.
The nurse should monitor the client’s potassium levels and advise them to eat foods rich in potassium, such as bananas, oranges, or potatoes.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg.
Normal ranges for blood sugar are 4.0 mmol/L to 7.8 mmol/L (72 mg/dL to 140 mg/dL).
Normal ranges for potassium are 3.5 mmol/L to 5.0 mmol/L (3.5 mEq/L to 5.0 mEq/L).
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.
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