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An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?
- A. Auscultate for renal bruits
- B. Obtain a clean catch mid-stream specimen
- C. Use a dipstick to measure for urinary ketones
- D. Begin to strain the client's urine
Correct Answer: B
Rationale: This elderly client is presenting symptoms consistent with a urinary tract infection (UTI), such as confusion, nausea, dysuria, urgency, and incontinence. The best course of action for the nurse is to obtain a clean catch mid-stream specimen. This specimen will help identify the causative agent of the UTI, allowing for targeted treatment with an appropriate anti-infective agent. Auscultating for renal bruits (Choice A) is not indicated in this scenario as the client's symptoms point towards a UTI rather than a renal issue. Using a dipstick to measure for urinary ketones (Choice C) is not relevant in the context of UTI symptoms. Beginning to strain the client's urine (Choice D) would not address the need to identify the causative agent for targeted treatment.
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The client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value is most concerning?
- A. Serum potassium of 6.0 mEq/L
- B. Serum creatinine of 2.5 mg/dL
- C. Serum calcium of 8.0 mg/dL
- D. Hemoglobin of 10 g/dL
Correct Answer: A
Rationale: A serum potassium level of 6.0 mEq/L is most concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, which can lead to serious cardiac complications such as arrhythmias and cardiac arrest. Immediate intervention is required to lower potassium levels.
Choice B, serum creatinine of 2.5 mg/dL, is elevated but expected in ESRD due to impaired kidney function. Choice C, serum calcium of 8.0 mg/dL, is within the normal range and not typically a priority in this situation. Choice D, hemoglobin of 10 g/dL, is slightly low but not an immediate concern for a client scheduled for hemodialysis unless significantly lower and causing severe symptoms.
A client is being treated with an aminoglycoside antibiotic for a serious gram-negative infection. What nursing action should be included in the plan of care to prevent nephrotoxicity?
- A. Monitor serum creatinine levels daily.
- B. Administer the antibiotic over a longer period of time.
- C. Encourage increased fluid intake.
- D. Restrict dietary protein intake.
Correct Answer: A
Rationale: Monitoring serum creatinine levels daily is the essential nursing action to prevent nephrotoxicity from aminoglycoside antibiotics. Aminoglycosides can cause kidney damage, so monitoring serum creatinine levels helps in detecting early signs of nephrotoxicity. Administering the antibiotic over a longer period of time (choice B) does not directly prevent nephrotoxicity. Encouraging increased fluid intake (choice C) is a general good practice but not specifically aimed at preventing nephrotoxicity. Restricting dietary protein intake (choice D) is not a direct preventive measure against aminoglycoside-induced nephrotoxicity.
An older female client tells the nurse that her muscles have gradually been getting weaker. What is the best initial response by the nurse?
- A. Explain that this is an expected occurrence with aging.
- B. Observe the lower extremities for signs of muscle atrophy.
- C. Review the medical record for recent diagnostic test results.
- D. Ask the client to describe the changes that have occurred.
Correct Answer: D
Rationale: The best initial response by the nurse when the client reports muscle weakness is to ask the client to describe the changes that have occurred. This approach allows the nurse to gain a better understanding of the client's experience, the extent of weakness, any associated symptoms, and potential triggers. By actively listening to the client's description, the nurse can gather valuable information that will aid in a comprehensive assessment and development of a tailored care plan. Choice A is incorrect because assuming muscle weakness is solely due to aging without further assessment can lead to overlooking potential underlying causes. Choice B is incorrect as observing for signs of muscle atrophy should come after gathering information directly from the client. Choice C is incorrect as reviewing diagnostic test results should not be the initial step when the client's current experience is being shared.
The nurse is caring for a client with chronic kidney disease (CKD). Which laboratory value should be reported to the healthcare provider immediately?
- A. Serum creatinine of 2.0 mg/dl
- B. Hemoglobin of 10 g/dl
- C. Potassium of 6.5 mEq/L
- D. Blood glucose of 150 mg/dl
Correct Answer: C
Rationale: The correct answer is C. A potassium level of 6.5 mEq/L is dangerously high, a condition known as hyperkalemia, and requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, making it crucial to notify the healthcare provider promptly. Choices A, B, and D do not indicate immediate life-threatening conditions. Elevated serum creatinine levels are expected in CKD, a hemoglobin level of 10 g/dl is within a reasonable range, and a blood glucose level of 150 mg/dl is not acutely concerning in this context.
A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which laboratory value requires immediate intervention?
- A. Serum glucose of 600 mg/dL
- B. Serum osmolarity of 320 mOsm/kg
- C. Serum sodium of 130 mEq/L
- D. Serum potassium of 5.0 mEq/L
Correct Answer: B
Rationale: A serum osmolarity of 320 mOsm/kg is concerning in a client with HHS because it indicates severe dehydration and hyperosmolarity, which requires immediate intervention. In HHS, the elevated serum osmolarity leads to neurological symptoms and can result in serious complications if not addressed promptly. While a high serum glucose level (choice A) is typical in HHS, the osmolarity is a more direct indicator of dehydration and severity. Serum sodium (choice C) and potassium levels (choice D) are important but do not pose an immediate threat to the client's condition compared to the severe hyperosmolarity indicated by a high serum osmolarity level.