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 A
Explanation
A. Confusion: Respiratory acidosis (low pH + high PaCO2) leads to decreased oxygenation of brain tissues, causing confusion, drowsiness, and lethargy.
B. Kussmaul's Respirations: Seen in metabolic acidosis, not respiratory acidosis.
C. Seizures: Seizures are more common with alkalosis (high pH) due to neuronal excitability.
D. Paresthesia in the Extremities: More common in respiratory alkalosis due to calcium shifts.
Correct Answer is A
Explanation
A. Place the client on seizure precautions: Metabolic alkalosis can cause neuromuscular excitability, increasing the risk of seizures.
B. Encourage the client to breathe slowly: Slow breathing retains CO₂, which worsens alkalosis. The body needs hypoventilation, but this cannot be forced.
C. Plan to administer sodium bicarbonate to the client: Sodium bicarbonate worsens alkalosis and is only used in metabolic acidosis, not alkalosis.
D. Have the client breathe into a paper bag: This is a treatment for respiratory alkalosis, not metabolic alkalosis.
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