a client with acute kidney injury has an elevated creatinine level what is the nurses priority intervention
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2023 Capstone

1. A client with acute kidney injury has an elevated creatinine level. What is the nurse's priority intervention?

Correct answer: B

Rationale: The correct answer is B: Prepare the client for dialysis. Clients with acute kidney injury and elevated creatinine may require dialysis to support kidney function and remove waste products from the blood. Preparing for dialysis ensures timely intervention in preventing further complications. Administering diuretics (Choice A) may worsen the client's condition by further compromising kidney function. Restricting fluid intake (Choice C) may be necessary in some cases, but it is not the priority over preparing for dialysis. Notifying the healthcare provider (Choice D) is important, but the immediate priority is to prepare for dialysis to address the acute kidney injury and elevated creatinine level.

2. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

Correct answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

3. A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?

Correct answer: A

Rationale: A pale foot with no pulse suggests a compromised blood supply, indicating a potential vascular emergency. The nurse's immediate priority is to notify the healthcare provider to address the situation promptly. Readjusting the traction, administering PRN medication, or waiting to reassess the foot later could lead to serious complications due to the compromised blood supply, making choices B, C, and D incorrect in this critical situation.

4. A client receiving full-strength continuous enteral tube feeding develops diarrhea. What intervention should the nurse take?

Correct answer: B

Rationale: When a client develops diarrhea from continuous enteral tube feeding, diluting the feeding to half strength and continuing at the same rate is the appropriate intervention. This helps reduce the strength of the feeding, minimizing gastrointestinal upset while still providing necessary nutrition. Stopping the feeding abruptly (Choice A) may lead to nutritional deficits. Simply reducing the feeding rate (Choice C) may not effectively address the issue of diarrhea. Adding fiber (Choice D) could potentially worsen the diarrhea in this scenario instead of resolving it.

5. A client admitted with left-sided heart failure presents with shortness of breath and pink frothy sputum. Which assessment finding requires immediate intervention?

Correct answer: C

Rationale: Correct Answer: Pink frothy sputum and increased respiratory rate. Pink frothy sputum is a sign of pulmonary edema, indicating fluid in the lungs, a life-threatening condition that requires immediate intervention to prevent respiratory failure. Increased respiratory rate is also concerning as it indicates the body's effort to compensate for the decreased oxygenation. Options A, B, and D are not the most critical findings in this situation. Decreased breath sounds bilaterally may indicate a pneumothorax or atelectasis, heart rate of 110 bpm and irregular rhythm can be managed with medications and further assessment, and elevated blood pressure with shortness of breath is not as urgent as pink frothy sputum and increased respiratory rate.

Similar Questions

The nurse is teaching a group of clients about managing diabetes. Which of the following should be emphasized as a goal for all diabetics?
A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the therapeutic response, which assessment should the nurse obtain?
The nurse is preparing to administer an intramuscular injection to an adult client. Which site should the nurse select?
A client is admitted with diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to find in this client?
A client reports unilateral leg swelling after a long flight. What complication is the nurse most concerned about?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses