The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which intervention should the nurse perform?
Provide water for a client diagnosed with chronic kidney disease
Instruct the client on appropriate fluid restrictions
Measure the client's output from the indwelling catheter
Record the client’s intake and output in the EMR
The Correct Answer is B
A. Provide water for a client diagnosed with chronic kidney disease: Fluid intake must be controlled in CKD. A nurse should determine if water intake is appropriate.
B. Instruct the client on appropriate fluid restrictions: Client education is a nursing responsibility and cannot be delegated to a UAP. The nurse should educate clients on fluid restrictions in conditions like chronic kidney disease (CKD) to prevent fluid overload and electrolyte imbalances.
C. Measure the client’s output from the indwelling catheter: This task can be delegated to a UAP.
D. Record the client’s intake and output in the EMR: UAPs can record I&O but cannot interpret the data.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. pH 7.30, PaCO₂ 38, HCO₃ 15: Metabolic acidosis (low HCO₃, normal PaCO₂).
B. pH 7.32, PaCO₂ 56, PO₂ 84, HCO₃ 26: The client has respirations of 8/min, which indicates hypoventilation → CO₂ retention → respiratory acidosis. pH 7.32 indicates acidosis. PaCO₂ 56 mmHg - Elevated CO₂ (hypercapnia), confirming respiratory acidosis. HCO₃ 26- Normal bicarbonate suggests that compensation has not yet occurred
C. pH 7.37, PaCO₂ 45, HCO₃ 24: Normal ABG values.
D. pH 7.48, PaCO₂ 32, HCO₃ 22: Respiratory alkalosis (low PaCO₂ due to hyperventilation, not hypoventilation).
Correct Answer is A
Explanation
A. Prepare the client for dialysis: A potassium level of 8.3 mEq/L is critically high (normal range: 3.5–5.3 mEq/L), putting the client at immediate risk for life-threatening cardiac arrhythmias (e.g., ventricular fibrillation). Emergency dialysis is needed to remove excess potassium if other interventions (e.g., insulin, calcium gluconate) fail.
B. Start an IV and run normal saline at 50mL/hour: Fluid administration alone does not lower potassium quickly enough in a life-threatening situation.
C. Repeat the electrolyte values later in the day: Delaying treatment would increase the risk of cardiac arrest.
D. Monitor urine output: Although important, monitoring alone does not treat the emergency. Clients with acute renal failure often have little to no urine output.
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