The practical nurse (PN) identifies an electrolyte imbalance, an elevated blood pressure, and exhibited changes in mental status for a client with acute kidney injury (AKI). Which intervention in the plan of care should the PN implement?
Discuss a low sodium diet.
Provide only distilled water.
Monitor for dependent pitting edema.
Use a cushion when sitting.
The Correct Answer is C
A. Discuss a low sodium diet: While teaching about a low sodium diet is important in managing fluid balance and hypertension, it is not the immediate intervention needed to address the acute symptoms and risks associated with the client's current condition.
B. Provide only distilled water: Distilled water is not necessary in managing acute kidney injury. Fluid intake management should be based on specific electrolyte and fluid needs, and the focus should be on controlling volume overload rather than the type of water provided.
C. Monitor for dependent pitting edema: Monitoring for pitting edema is critical because it provides immediate information about fluid overload, which is common with acute kidney injury. Assessing for edema provides information about the extent of fluid retention and helps evaluate the effectiveness of interventions aimed at managing fluid balance.
D. Use a cushion when sitting: Using a cushion may improve comfort but does not address the life-threatening complications of electrolyte imbalance, hypertension, and mental status changes associated with acute kidney injury. Priority should be on assessing and managing systemic symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Notify the unit charge nurse of the client's reported symptoms immediately: Tingling and numbness can be signs of hyperkalemia, a serious and potentially life-threatening complication from potassium supplementation. Immediate reporting is necessary for prompt evaluation and intervention to prevent cardiac or neuromuscular complications.
B. Reassure the client that the supplement will soon relieve those symptoms: Symptoms like tingling and numbness are not expected side effects of potassium therapy. Reassurance without investigation could delay necessary medical treatment and worsen the client’s condition.
C. Explain that a calcium supplement may be necessary: Calcium supplementation is not the standard response to symptoms of potassium imbalance. Without a clear diagnosis, recommending additional supplements could complicate the clinical situation further.
D. Encourage the client to decrease the intake of dietary sodium: Although reducing sodium is generally beneficial for health, it does not address the acute issue of possible potassium imbalance causing neuromuscular symptoms. Immediate clinical evaluation takes priority.
Correct Answer is B
Explanation
A. Offer fluids: Offering fluids is not appropriate when the client shows signs of central cyanosis, as it does not address impaired oxygenation and may pose an aspiration risk if the client is hypoxic or has altered mental status.
B. Administer oxygen: Cyanosis of the lips and tongue indicates poor oxygen saturation and tissue hypoxia. Administering oxygen is the priority action to improve oxygen delivery and prevent respiratory compromise.
C. Ask about pain: While assessing pain is important, it is not the priority in the presence of cyanosis, which reflects a potentially life-threatening oxygenation issue requiring immediate intervention.
D. Provide mouth care: Mouth care is not urgent and does not address the underlying problem of hypoxia. It should be deferred until after the client’s oxygenation status is stabilized.
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