A nurse is assigned to care for four children who have acute kidney injury (AKI). Which child should the nurse see first after obtaining the handoff report?
A.
Anuric
B.
Oliguric
C.
Has deep, rapid respirations
D.
Having in-room dialysis
ANS: A
Children with AKI generally are not anuric unless a catastrophic event has occurred. The nurse needs to see this child first. Oliguria (low urine output) is an expected finding unless the child is in the diuretic phase (high-output phase) of AKI. Deep rapid respirations (Kussmaul's respirations) are also expected as a compensatory response to the metabolic acidosis of AKI. A child receiving dialysis in the room is being attended to by a dialysis nurse.
You might also like to view...
A nurse who is a chronic complainer comes back from lunch 20 minutes late. When confronted by the manager the nurse says, "The nurses who smoke always take longer lunches. No one says anything to them
" What is the manager's major consideration before replying to this statement? 1. Policies must be consistently applied to all employees. 2. Since the hospital is smoke free, those nurses who wish to smoke must leave campus for lunch. 3. This nurse complains about everything. 4. The human resources policy is that nurses get 60 minutes for lunch.
A nurse made a home visit for prenatal care and teaching for an Asian woman. The nurse noted the woman was having a hot lunch of foods the nurse did not recognize
When the nurse suggested some appropriate cold protein foods be added to the meal, the woman looked horrified and distrusting. Which of the following best describes what has happened in this situation? a. The interference with eating seemed incredibly intrusive and inappropriate. b. The nurse was giving advice when advice had not been sought. c. The nurse had suggested foods unknown to the woman. d. The yin and yang theory requires only hot food be eaten when female yin energy is dominant.
A new mother says to the nurse, "It really hurts me to breastfeed. I think I should wean my baby." The most appropriate response by the nurse is,
a. "It is good to wean the baby early because it is easier on you." b. "If I understand you, it hurts when you breastfeed. Tell me how and when it hurts." c. "It is your decision to make whether you breastfeed." d. "You should continue to breastfeed because it is much better for the baby."
The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding?
a. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." b. "When patients say they don't need pain medication, they aren't in pain." c. "Pain assessment scales determine the quality of a patient's pain." d. "A patient's behavior is more reliable than the patient's report of pain."