Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?
A. Place the patient on a cardiac monitor.
In the case of hyperkalemia, which can cause fatal cardiac arrhythmias, the most immediate nursing action is to place the patient on a cardiac monitor. This allows for continuous monitoring of the heart's rhythm and immediate detection of any life-threatening changes, which is crucial for timely intervention.
B. Insert a urinary retention catheter.
Inserting a urinary retention catheter may be necessary for managing oliguria, but it is not the most urgent action when compared to the potential cardiac risks associated with hyperkalemia.
C. Give the prescribed spironolactone.
Administering spironolactone, a potassium-sparing diuretic, could be part of the treatment for hyperkalemia, but it is not the first action to take. Spironolactone works more slowly and does not address the immediate risk of cardiac arrhythmias.
D. Administer epoetin alfa (Epogen).
Epoetin alfa (Epogen) is used to treat anemia, particularly in chronic kidney disease, to increase red blood cell production. However, it does not have an immediate effect and is not the priority in the presence of hyperkalemia and potential cardiac complications.
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Full Explanation
Choice A rationale
In the case of hyperkalemia, which can cause fatal cardiac arrhythmias, the most immediate nursing action is to place the patient on a cardiac monitor. This allows for continuous monitoring of the heart's rhythm and immediate detection of any life-threatening changes, which is crucial for timely intervention.
Choice B rationale
Inserting a urinary retention catheter may be necessary for managing oliguria, but it is not the most urgent action when compared to the potential cardiac risks associated with hyperkalemia.
Choice C rationale
Administering spironolactone, a potassium-sparing diuretic, could be part of the treatment for hyperkalemia, but it is not the first action to take. Spironolactone works more slowly and does not address the immediate risk of cardiac arrhythmias.
Choice D rationale
Epoetin alfa (Epogen) is used to treat anemia, particularly in chronic kidney disease, to increase red blood cell production. However, it does not have an immediate effect and is not the priority in the presence of hyperkalemia and potential cardiac complications.
Similar Questions
A nurse is teaching a client who has hepatitis A about preventing the transmission of the virus. Which of the following strategies should the nurse include in the teaching?
A. Wear barrier protection during vaginal intercourse.
Wearing barrier protection during vaginal intercourse is a general precaution to prevent the transmission of sexually transmitted infections (STIs), including hepatitis B and C. However, hepatitis A is primarily transmitted through the fecal-oral route, not sexual contact.
B. Avoid sharing needles with others.
Avoiding needle sharing is critical for preventing the spread of bloodborne pathogens, including hepatitis B and C. While it is always good practice, hepatitis A is not typically transmitted through blood.
C. Avoid eating at fast food restaurants.
The suggestion to avoid eating at fast food restaurants does not directly relate to the prevention of hepatitis A. The virus is usually spread through contaminated food or water, so ensuring food safety is important, but singling out fast food restaurants is not necessary.
D. Practice effective hand hygiene.
Practicing effective hand hygiene is the most effective way to prevent the transmission of hepatitis A. The virus can be spread through close contact or ingestion of contaminated food or water, so washing hands can significantly reduce the risk.
Full Explanation
Choice A rationale
Wearing barrier protection during vaginal intercourse is a general precaution to prevent the transmission of sexually transmitted infections (STIs), including hepatitis B and C. However, hepatitis A is primarily transmitted through the fecal-oral route, not sexual contact.
Choice B rationale
Avoiding needle sharing is critical for preventing the spread of bloodborne pathogens, including hepatitis B and C. While it is always good practice, hepatitis A is not typically transmitted through blood.
Choice C rationale
The suggestion to avoid eating at fast food restaurants does not directly relate to the prevention of hepatitis A. The virus is usually spread through contaminated food or water, so ensuring food safety is important, but singling out fast food restaurants is not necessary.
Choice D rationale
Practicing effective hand hygiene is the most effective way to prevent the transmission of hepatitis A. The virus can be spread through close contact or ingestion of contaminated food or water, so washing hands can significantly reduce the risk.
A nurse is providing discharge education to a client diagnosed with fluid volume excess (FVE) due to liver failure. Which of the following meal options should the nurse recommend for the client?
A. Canned soup
Canned soup is typically high in sodium, which can worsen fluid volume excess (FVE). Patients with liver failure need to limit sodium intake to reduce fluid retention.
B. Baked chicken breast
Baked chicken breast is a low-sodium and protein-rich option suitable for clients with liver failure. Protein is essential for tissue repair and maintaining fluid balance within the body.
C. Bowl of ice cream
A bowl of ice cream is high in sugar and fat, which can be difficult for a liver-compromised patient to process and may contribute to further fluid retention.
D. Spaghetti with commercial red sauce
Spaghetti with commercial red sauce can be high in sodium due to the sauce, which is not recommended for clients with FVE as it may exacerbate their condition.
Full Explanation
Choice A rationale
Canned soup is typically high in sodium, which can worsen fluid volume excess (FVE). Patients with liver failure need to limit sodium intake to reduce fluid retention.
Choice B rationale
Baked chicken breast is a low-sodium and protein-rich option suitable for clients with liver failure. Protein is essential for tissue repair and maintaining fluid balance within the body.
Choice C rationale
A bowl of ice cream is high in sugar and fat, which can be difficult for a liver-compromised patient to process and may contribute to further fluid retention.
Choice D rationale
Spaghetti with commercial red sauce can be high in sodium due to the sauce, which is not recommended for clients with FVE as it may exacerbate their condition.
A nurse is teaching a client who has peripheral venous disease about the management of symptoms. Which of the following client statements indicates an understanding of the teaching?
A. "I will need to massage my legs frequently to prevent a buildup of fluid."
Massaging the legs frequently is not recommended for peripheral venous disease as it can dislodge clots that may be present, leading to serious complications.
B. "I will keep my legs in a dependent position."
Keeping the legs in a dependent position can worsen the symptoms of peripheral venous disease by increasing venous pressure and swelling.
C. "I will inspect my legs every day for changes in color, size, and temperature."
Inspecting the legs daily for changes is a key part of self-management for peripheral venous disease. It helps in early detection of potential complications.
D. "I will decrease my activity to prevent added stress on my legs."
Decreasing activity is not advised unless specified by a healthcare provider. Regular activity can actually help improve circulation and manage symptoms.
Full Explanation
Choice A rationale
Massaging the legs frequently is not recommended for peripheral venous disease as it can dislodge clots that may be present, leading to serious complications.
Choice B rationale
Keeping the legs in a dependent position can worsen the symptoms of peripheral venous disease by increasing venous pressure and swelling.
Choice C rationale
Inspecting the legs daily for changes is a key part of self-management for peripheral venous disease. It helps in early detection of potential complications.
Choice D rationale
Decreasing activity is not advised unless specified by a healthcare provider. Regular activity can actually help improve circulation and manage symptoms.