The nurse is developing a plan of care for a client diagnosed with acute renal failure (ARF). Which statement would be an appropriate outcome for the client?
Electrolytes are within normal limits.
Blood pressure is decreased to 120/80
Decrease of pain by 3 points on a 1-10 scale.
The client will understand how to care for the AV fistula
The Correct Answer is A
A. Electrolytes are within normal limits: Acute Renal Failure (ARF) leads to electrolyte imbalances (↑ K+, ↑ BUN/creatinine, metabolic acidosis). A successful treatment goal is restoring normal electrolyte balance.
B. Blood pressure is decreased to 120/80. BP control is important but not the primary goal in ARF.
C. Decrease of pain by 3 points on a 1-10 scale. Pain control is important, but not the main indicator of ARF improvement.
D. The client will understand how to care for the AV fistula. This applies to chronic kidney disease clients on hemodialysis, not ARF management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is B
Explanation
A. Respiratory Alkalosis: Would have low PaCO2 (<35 mmHg), not high.
B. Partially Compensated Metabolic Alkalosis: The pH is high (alkalosis), and the HCO3 is elevated, which indicates metabolic alkalosis. The PaCO2 is high, meaning the lungs are attempting to compensate by retaining CO₂ to lower the pH. Because the pH is still abnormal, this is partial compensation.
C. Metabolic Acidosis: Would have low pH and low HCO3 (<22 mEq/L).
D. Fully Compensated Respiratory Acidosis: The primary problem is metabolic, not respiratory.
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