The nurse is admitting a client diagnosed with acute renal failure (ARF). The nursing assessment will prioritize ...
Urine output and electrolyte levels.
Understanding of how to prevent falls.
Peripheral vascular perfusion and pain.
Risk for bleeding and white blood cell count (WBC)
The Correct Answer is A
Acute renal failure is characterized by a sudden decline in kidney function, resulting in the inability of the kidneys to adequately filter waste products and maintain fluid and electrolyte balance. Monitoring urine output is essential in assessing kidney function and determining the severity of renal failure. A decrease in urine output or anuria may indicate worsening renal function and the need for immediate interventions.
Assessing electrolyte levels, such as sodium, potassium, calcium, and phosphorus, is crucial because renal failure can disrupt the balance of these electrolytes in the body. Imbalances can lead to complications such as electrolyte abnormalities, cardiac dysrhythmias, and neuromuscular disturbances. Prompt identification and management of electrolyte imbalances are essential in preventing further complications and supporting optimal patient outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client's symptoms of bounding peripheral pulses, weight gain, pitting edema, and moist crackles bilaterally suggest fluid volume overload or fluid retention. Furosemide (Lasix) is a loop diuretic that helps to promote diuresis and reduce fluid volume. Administering the medication promptly can help address the client's symptoms and alleviate the fluid overload.
Correct Answer is A
Explanation
Unequal scapula and hip heights can be indicative of spinal curvature, a key characteristic of scoliosis. As the spine curves, it can cause the shoulders and hips to appear uneven when observed from behind. This asymmetry is an important visual clue that warrants further assessment and evaluation.
Equal rib prominence and tight-fitting clothes, equal waist and shoulder angles, and symmetric chest expansion with deep breaths are not specific signs of scoliosis. These signs may not be affected by spinal curvature and are not typically used in the screening process for scoliosis.
It's important to note that scoliosis screenings may involve more comprehensive assessments, including the use of scoliometers or other measuring tools to evaluate the degree of spinal curvature. Any concerns or suspicions of scoliosis should be reported to appropriate healthcare professionals for further evaluation and management.
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