The primary purpose of an ileostomy in a patient with Crohn’s disease is to divert stool away from the diseased portion of the intestine, allowing it to heal and reducing symptoms.

POP QUIZ Medical Surgical Question

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Medical-Surgical Nursing Questions: Colitis Treatments

Medical Surgical Question 2: A 45-year-old patient with rectal cancer undergoes surgery that results in a permanent ileostomy. What should be the focus of post-operative nursing care for this patient?

For a patient with a permanent ileostomy following rectal cancer surgery, the primary focus of post-operative nursing care should be on promoting psychological adjustment to body changes and providing emotional support.

Medical Surgical Question 3: A 55-year-old patient with an ileostomy is concerned about odor control. Which intervention can help minimize odor from the ileostomy pouch?

Minimizing odor from an ileostomy pouch can be achieved by using pouch deodorizers, which help neutralize odors. Frequent pouch changes may increase the risk of skin irritation.

Medical-Surgical Nursing Questions Focus on Colitis: Causes and Diagnosis

Medical Surgical Question 4: A 60-year-old patient with an ileostomy reports loose stools and increased frequency of emptying the pouch. What nursing advice should be provided to address this issue?

If a patient with an ileostomy experiences loose stools and increased pouch emptying, the nursing advice should include increasing oral intake of electrolyte-rich fluids to prevent dehydration and maintain electrolyte balance.

Medical Surgical Question 5: A 65-year-old patient with an ileostomy is concerned about skin irritation around the stoma. What nursing measures can help prevent skin problems in this patient?

To prevent skin problems around the stoma in a patient with an ileostomy, it is essential to keep the peristomal skin clean and dry. Avoiding skin barrier use and applying adhesive to wet or irritated skin can worsen skin issues.

The most indicative laboratory test of hepatic failure in a patient with chronic liver disease presenting with jaundice and abdominal distension is an elevated serum bilirubin level. Elevated bilirubin levels are characteristic of impaired liver function.

Medical Surgical Question 7: A 60-year-old patient with suspected hepatic encephalopathy is admitted to the hospital. Which lab test can help confirm the diagnosis of hepatic encephalopathy?

The lab test that can help confirm the diagnosis of hepatic encephalopathy is the serum ammonia level. Elevated ammonia levels are associated with hepatic encephalopathy, indicating impaired ammonia detoxification by the liver.

Medical-Surgical Nursing Questions: Understanding Colitis Causes and Symptoms

Medical Surgical Question 8: A 45-year-old patient with hepatic cirrhosis is being monitored for bleeding risk. Which laboratory parameter should be assessed to evaluate coagulation status in this patient?

To evaluate the coagulation status and bleeding risk in a patient with hepatic cirrhosis, the prothrombin time (PT) should be assessed. Prolonged PT indicates impaired liver synthesis of clotting factors.

Medical Surgical Question 9: A 50-year-old patient with hepatic failure is experiencing fluid retention and edema. Which lab test can help assess the patient’s kidney function and fluid balance?

To assess kidney function and fluid balance in a patient with hepatic failure and fluid retention, the serum creatinine level should be measured. Elevated creatinine levels may indicate kidney dysfunction.

Medical Surgical Question 10: A 65-year-old patient with advanced liver disease is at risk of gastrointestinal bleeding. Which lab test can help assess the patient’s platelet count and clotting function?

To assess platelet count and clotting function in a patient with advanced liver disease at risk of gastrointestinal bleeding, both the platelet count and international normalized ratio (INR) should be evaluated. These tests provide information about bleeding risk.

Understanding Colitis: Causes and Symptoms

Medical Surgical Question 11: A 45-year-old patient underwent surgery for rectal cancer and now has a colostomy. What is the primary purpose of a colostomy in this patient?

The primary purpose of a colostomy in a patient who underwent surgery for rectal cancer is to divert stool away from the diseased portion of the intestine, allowing it to heal and reducing symptoms.

Understanding Colitis: Medical-Surgical Nursing Questions

Medical Surgical Question 12: A 50-year-old patient with a new colostomy is worried about body image changes. What should be the focus of nursing care to address this concern?

The primary focus of nursing care for a patient with a new colostomy who is worried about body image changes should be on promoting psychological adjustment to body changes and providing emotional support.

Understanding Colitis: Medical-Surgical Nursing High Yield Questions

Medical Surgical Question 13: A 55-year-old patient with a colostomy is concerned about odor control. Which intervention can help minimize odor from the colostomy pouch?

Minimizing odor from a colostomy pouch can be achieved by using pouch deodorizers, which help neutralize odors. Frequent pouch changes may increase the risk of skin irritation.

Medical-Surgical Nursing Questions: Colitis Questions, Answers and Rationales

Medical Surgical Question 14: A 60-year-old patient with a colostomy reports changes in stool consistency and increased frequency of emptying the pouch. What nursing advice should be provided to address this issue?

If a patient with a colostomy experiences changes in stool consistency and increased pouch emptying, the nursing advice should include increasing dietary fiber intake to help regulate stool consistency and reduce frequent emptying.

Medical Surgical Question 15: A 65-year-old patient with a colostomy is concerned about skin irritation around the stoma. What nursing measures can help prevent skin problems in this patient?

To prevent skin problems around the stoma in a patient with a colostomy, it is essential to keep the peristomal skin clean and dry. Avoiding skin barrier use and applying adhesive to wet or irritated skin can worsen skin issues.

Understanding Colitis: Medical-Surgical Nursing Priority Questions

Medical Surgical Question 16: A 45-year-old patient underwent surgery for rectal cancer and now has a colostomy. What is the primary purpose of a colostomy in this patient?

The primary purpose of a colostomy in a patient who underwent surgery for rectal cancer is to divert stool away from the diseased portion of the intestine, allowing it to heal and reducing symptoms.

Medical Surgical Question 17: A 50-year-old patient with a new colostomy is worried about body image changes. What should be the focus of nursing care to address this concern?

The primary focus of nursing care for a patient with a new colostomy who is worried about body image changes should be on promoting psychological adjustment to body changes and providing emotional support.

Understanding Colitis: Medical-Surgical Nursing Delegation Questions

Medical Surgical Question 18: A 55-year-old patient with a colostomy is concerned about odor control. Which intervention can help minimize odor from the colostomy pouch?

Minimizing odor from a colostomy pouch can be achieved by using pouch deodorizers, which help neutralize odors. Frequent pouch changes may increase the risk of skin irritation.

Medical Surgical Question 19: A 60-year-old patient with a colostomy reports changes in stool consistency and increased frequency of emptying the pouch. What nursing advice should be provided to address this issue?

If a patient with a colostomy experiences changes in stool consistency and increased pouch emptying, the nursing advice should include increasing dietary fiber intake to help regulate stool consistency and reduce frequent emptying.

Medical Surgical Question 20: A 65-year-old patient with a colostomy is concerned about skin irritation around the stoma. What nursing measures can help prevent skin problems in this patient?

To prevent skin problems around the stoma in a patient with a colostomy, it is essential to keep the peristomal skin clean and dry. Avoiding skin barrier use and applying adhesive to wet or irritated skin can worsen skin issues.

The primary goal of gastric bypass surgery in bariatric patients is to restrict food intake and promote early satiety, leading to weight loss and improved metabolic health.

A 35-year-old bariatric patient is concerned about nutritional deficiencies after weight loss surgery. What nutrient supplementation is typically recommended post-bariatric surgery?

After weight loss surgery, bariatric patients are often recommended to take iron and vitamin B12 supplements to prevent nutritional deficiencies, as these nutrients may be poorly absorbed due to alterations in the digestive tract.

A 50-year-old bariatric patient is experiencing dumping syndrome after meals. What dietary recommendations should be provided to manage this condition?

For bariatric patients experiencing dumping syndrome, dietary recommendations include eating small, frequent meals and avoiding excessive sugar intake, high-fat foods, and fluid intake with meals to manage symptoms.

A 45-year-old bariatric patient is concerned about regaining weight after surgery. What behavioral strategies can help prevent weight regain in this patient?

To prevent weight regain after bariatric surgery, behavioral strategies such as practicing mindful eating and engaging in regular physical activity are essential. Restrictive diets and skipping meals are not recommended.

A 55-year-old bariatric patient experiences severe abdominal pain and vomiting after meals. What could be a potential complication in this patient, and how should it be managed?

The patient’s symptoms are suggestive of dumping syndrome, a common complication after bariatric surgery. Dumping syndrome is managed with dietary modifications (avoiding high-sugar meals) and medication as needed to alleviate symptoms.

A 35-year-old patient presents with unexplained weight gain over the past six months. The patient’s thyroid function tests reveal elevated levels of thyroid-stimulating hormone (TSH). What is the most likely cause of the weight gain in this patient?

The most likely cause of unexplained weight gain in this patient with elevated TSH levels is hypothyroidism. Hypothyroidism can slow down metabolism, leading to weight gain despite normal calorie intake.

A 45-year-old patient with a history of depression reports significant weight gain after starting a new antidepressant medication. Which class of antidepressants is most commonly associated with weight gain?

Weight gain is most commonly associated with the use of selective serotonin reuptake inhibitors (SSRIs), a class of antidepressant medications often prescribed for depression and anxiety.

A 55-year-old patient with type 2 diabetes is struggling with weight gain despite efforts to control blood sugar levels. What medication class should be considered for weight management in this patient with diabetes?

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a class of medications that can be considered for weight management in patients with type 2 diabetes. These medications may lead to weight loss in addition to their blood sugar-lowering effects.

A 50-year-old patient with a history of heart disease is concerned about weight gain while taking medications. Which cardiovascular medication class is least likely to contribute to weight gain?

Diuretics are the cardiovascular medication class least likely to contribute to weight gain. In fact, diuretics are often used to reduce fluid retention and promote weight loss.

A 60-year-old patient with chronic obstructive pulmonary disease (COPD) has gained weight over the past year, which is impacting respiratory function. What dietary approach should be recommended to help manage weight in this patient?

For a patient with COPD who needs to manage weight gain, a balanced diet with controlled portion sizes is recommended. This approach helps control calorie intake while providing essential nutrients for respiratory health.

A 45-year-old patient has recently experienced significant unintentional weight loss. The patient reports a persistent cough and chest pain. What condition should the nurse suspect as the cause of the weight loss in this patient?

The nurse should suspect lung cancer as the potential cause of significant unintentional weight loss in a patient with a persistent cough and chest pain. Weight loss is a common symptom of malignancies.

A 50-year-old patient with a history of type 2 diabetes is attempting to lose weight. What dietary approach is most effective for managing weight in patients with diabetes?

A low-glycemic index diet is the most effective dietary approach for managing weight in patients with diabetes. This approach helps control blood sugar levels and may aid in weight management.

A 55-year-old patient is considering bariatric surgery as a weight loss option. What is the primary goal of bariatric surgery?

The primary goal of bariatric surgery is long-term weight loss maintenance. Bariatric procedures are designed to help patients achieve sustained weight loss and improve overall health.

A 60-year-old patient with a history of hypertension is concerned about weight gain while taking antihypertensive medications. Which class of antihypertensive medications is often associated with weight gain?

Beta-blockers are a class of antihypertensive medications that are often associated with weight gain. Patients taking beta-blockers should be monitored for changes in weight.

A 65-year-old patient with a history of chronic obstructive pulmonary disease (COPD) has experienced weight loss due to reduced appetite and difficulty eating. What nursing interventions should be implemented to address weight loss in this patient?

For a patient with COPD experiencing weight loss due to reduced appetite, providing frequent snacks is a nursing intervention to help increase calorie intake and prevent further weight loss.

A 30-year-old patient presents to the emergency department with severe right lower quadrant abdominal pain. The patient describes the pain as sharp and worsening over the past 24 hours. What condition should the nurse suspect in this patient?

The nurse should suspect appendicitis in this patient with severe right lower quadrant abdominal pain, especially if the pain is sharp, worsening, and associated with other symptoms such as fever and nausea.

A 45-year-old patient presents with a history of chronic abdominal pain and bloating. The patient mentions experiencing alternating bouts of diarrhea and constipation. What gastrointestinal disorder is consistent with these symptoms?

The patient’s history of chronic abdominal pain, bloating, and alternating bouts of diarrhea and constipation is consistent with irritable bowel syndrome (IBS), a common gastrointestinal disorder characterized by abdominal discomfort and changes in bowel habits.

A 50-year-old patient presents with upper abdominal pain, nausea, and yellowing of the skin and eyes. What abdominal condition should the nurse suspect in this patient?

The combination of upper abdominal pain, nausea, and yellowing of the skin and eyes (jaundice) is indicative of pancreatitis, which is inflammation of the pancreas.

A 35-year-old patient complains of chronic abdominal pain that is relieved after having a bowel movement. The pain is associated with a change in the frequency and consistency of stools. What gastrointestinal condition is most likely causing these symptoms?

The patient’s description of chronic abdominal pain relieved after a bowel movement and associated with changes in stool frequency and consistency is typical of irritable bowel syndrome (IBS).

A 60-year-old patient presents with abdominal distention, tenderness, and guarding in the right upper quadrant. The patient also reports a history of alcohol abuse. What abdominal condition should be considered in this patient?

The patient’s abdominal findings, including distention, tenderness, guarding, and a history of alcohol abuse, raise suspicion of cirrhosis, which is liver scarring commonly associated with alcohol-related liver disease.

A 45-year-old patient with a history of gastrointestinal bleeding requires gastric decompression. Which type of nasogastric tube should the nurse select for this patient?

In this case, the nurse should select a Salem sump tube for gastric decompression. Salem sump tubes are specifically designed for gastrointestinal bleeding and decompression purposes.

A 65-year-old patient is receiving enteral nutrition via a nasogastric tube. The nurse notices that the tube is coiled in the patient’s mouth, making it difficult for the patient to tolerate. What action should the nurse take?

If the nasogastric tube is coiled in the patient’s mouth, the nurse should reposition the tube to ensure proper placement and comfort for the patient.

A 50-year-old patient is receiving continuous enteral feeding through a nasogastric tube. The nurse observes that the patient has developed diarrhea. What should the nurse assess to determine the cause of the diarrhea?

When a patient receiving enteral nutrition through a nasogastric tube develops diarrhea, the nurse should assess the enteral nutrition formula as it could be contributing to the diarrhea. Formula changes may be needed.

A 55-year-old patient has a nasogastric tube in place for gastric decompression. The nurse is preparing to administer medications through the tube. What important action should the nurse take before administering medications?

Before administering medications through a nasogastric tube, it is essential to verify the tube’s placement to ensure that the medications reach the intended location in the stomach.

A 40-year-old patient has a nasogastric tube for gastric suctioning. The nurse is responsible for maintaining proper tube patency. What action should the nurse take to prevent tube clogging?

To prevent nasogastric tube clogging, the nurse should flush the tube with warm water before and after each use. This helps maintain tube patency.

For a patient with dysphagia due to a stroke, a gastrostomy tube (G-tube) is the appropriate choice for enteral feeding, as it provides direct access to the stomach.

A 45-year-old patient with severe malnutrition is receiving enteral nutrition via a G-tube. The nurse notices that the G-tube is clogged and unresponsive to flushing. What action should the nurse take?

If a G-tube becomes clogged and unresponsive to flushing, it should be replaced to ensure proper enteral nutrition delivery and prevent complications.

A 55-year-old patient is receiving continuous enteral feeding through a J-tube. The nurse observes that the patient has developed diarrhea. What should the nurse assess to determine the cause of the diarrhea?

When a patient receiving enteral nutrition through a J-tube develops diarrhea, the nurse should assess the enteral nutrition formula, as it may be contributing to the diarrhea. Formula changes may be needed.

A 50-year-old patient with a G-tube is prescribed a medication that cannot be crushed or mixed with enteral formula. How should the nurse administer this medication?

If a medication cannot be crushed or mixed with enteral formula and the patient has a G-tube, the nurse should notify the healthcare provider to explore alternative medication options or administration routes.

A 35-year-old patient with a NET for enteral feeding has a high gastric residual volume (GRV) of 400 mL. What should the nurse do in response to this finding?

A high gastric residual volume (GRV) of 400 mL indicates delayed gastric emptying. In response, the nurse should hold the enteral feeding to prevent complications such as aspiration.

For a patient with a non-functional gastrointestinal tract, such as in this case, total parenteral nutrition (TPN) is the appropriate route of nutrition to meet their nutritional needs.

A 60-year-old patient is receiving TPN through a central venous catheter. The nurse notices that the TPN solution is cloudy. What action should the nurse take?

If the TPN solution appears cloudy, it may indicate contamination or the presence of particles. The nurse should stop the infusion and notify the healthcare provider for further assessment.

A 45-year-old patient receiving TPN experiences sudden shortness of breath and chest pain. What complication should the nurse suspect, and what immediate action should be taken?

The sudden onset of shortness of breath and chest pain in a patient receiving TPN suggests the possibility of an air embolism. The nurse should clamp the catheter to prevent further air entry and notify the healthcare provider.

A 50-year-old patient on TPN has developed diarrhea. What initial nursing intervention should be performed to address this issue?

If a patient on TPN develops diarrhea, the nurse should first assess the enteral feeding tube, as it may be a potential source of diarrhea. Ensuring proper placement and function is essential.

A 35-year-old patient receiving TPN complains of fever and chills. What action should the nurse take initially?

If a patient receiving TPN develops fever and chills, it may indicate infection. The nurse should stop the TPN infusion and obtain blood cultures to identify the source of infection.

A 60-year-old patient with a history of hypertension and heart failure is admitted to the hospital. The patient is on a low-sodium diet. Which food item should the nurse encourage the patient to avoid?

For a patient on a low-sodium diet due to hypertension and heart failure, canned soups are often high in sodium and should be avoided to manage blood pressure and fluid retention.

A 45-year-old patient with celiac disease is admitted to the hospital. Which type of diet should the nurse recommend for this patient?

A patient with celiac disease should follow a gluten-free diet, which is essential for managing symptoms and preventing gluten-related complications.

A 55-year-old patient with diabetes is undergoing surgery. What type of diet should be prescribed for the patient in the perioperative period?

Before surgery, patients are often placed on an NPO (Nothing by mouth) diet to prevent complications during anesthesia and surgery. The patient’s blood glucose levels will be closely monitored.

A 50-year-old patient with chronic kidney disease is on a renal diet. Which nutrient should the nurse closely monitor and restrict in this patient’s diet?

Patients with chronic kidney disease should closely monitor and restrict their sodium intake to manage blood pressure and fluid balance, as the kidneys may have difficulty processing sodium.

A 35-year-old pregnant patient is advised to increase her intake of which nutrient during pregnancy to support fetal development?

During pregnancy, it is important for the patient to increase her intake of folate (folic acid) to support fetal neural tube development and prevent neural tube defects.

A 45-year-old patient with chronic kidney disease is admitted with symptoms of hyperkalemia. What dietary modification should the nurse recommend to manage elevated potassium levels?

For a patient with hyperkalemia, it is crucial to restrict dietary potassium intake to prevent further elevation of potassium levels, which can be life-threatening.

A 50-year-old patient with heart failure is receiving diuretic therapy. The nurse is monitoring for signs of hypokalemia. What clinical manifestations should the nurse assess for?

Hypokalemia can lead to muscle weakness and ECG changes, including potentially life-threatening cardiac arrhythmias. Monitoring for these manifestations is essential in patients receiving diuretic therapy.

A 55-year-old patient with severe vomiting and diarrhea is at risk for dehydration and electrolyte imbalance. What laboratory values should the nurse closely monitor in this patient?

In a patient with severe vomiting and diarrhea, monitoring serum sodium and potassium levels is crucial as these electrolytes are often imbalanced in cases of dehydration.

A 60-year-old patient with a history of diabetes is admitted with symptoms of hyperglycemia, including excessive thirst and frequent urination. What electrolyte imbalance is commonly associated with hyperglycemia, and how should it be managed?

Hyperglycemia is commonly associated with hyponatremia. Management involves administering hypertonic saline to correct sodium levels while addressing hyperglycemia.

A 35-year-old patient with severe burns is at risk for fluid and electrolyte imbalances. What nursing intervention should be prioritized to monitor fluid status in this patient?

Monitoring daily weights is a critical nursing intervention to assess fluid status in a patient with severe burns. Sudden changes in weight can indicate fluid imbalances.

A 60-year-old patient underwent abdominal surgery yesterday and has not had a bowel movement since the procedure. The patient is experiencing abdominal distention and discomfort. Which intervention should the nurse prioritize?

In a postoperative patient with suspected paralytic ileus, encouraging early ambulation is a priority intervention to stimulate bowel motility and prevent complications related to immobility.

A 55-year-old patient with a history of chronic pain medicine use presents to the emergency department with severe abdominal pain, bloating, and constipation. The nurse suspects paralytic ileus. What medication should the nurse anticipate administering?

Naloxone is an antagonist that can reverse the effects of overdose, potentially relieving paralytic ileus in this patient with drug constipation.

A 70-year-old postoperative patient is at risk for paralytic ileus due to surgical manipulation of the bowel. What nursing intervention should be included in the plan of care to prevent paralytic ileus?

Early initiation of enteral nutrition is a key intervention to prevent paralytic ileus in postoperative patients. It promotes bowel motility and maintains gut function.

A 45-year-old patient is diagnosed with paralytic ileus and has not passed gas for the past 24 hours. What should the nurse auscultate for during abdominal assessment?

In a patient with paralytic ileus, bowel sounds are often absent or hypoactive. This indicates reduced or no peristalsis in the intestines.

A 50-year-old patient has developed abdominal distention and vomiting. An abdominal X-ray reveals a dilated bowel. What complication of paralytic ileus should the nurse suspect, and what intervention is needed?

In a patient with abdominal distention, vomiting, and a dilated bowel on X-ray, the nurse should suspect bowel perforation as a complication of paralytic ileus. Immediate surgical intervention is often required.

A 65-year-old patient underwent abdominal surgery two days ago. The patient now presents with separation of the surgical wound edges, accompanied by serosanguinous drainage. Which nursing intervention is the priority?

Wound dehiscence with serosanguinous drainage is indicative of wound separation. The priority is to prepare for surgical wound re-closure to prevent infection and further complications.

A 50-year-old patient with a history of obesity and diabetes underwent gastric bypass surgery. On postoperative day three, the patient reports a “popping” sensation and increased pain at the surgical site. Upon examination, the nurse observes separation of the wound edges with visible underlying tissues. What should the nurse suspect?

The “popping” sensation, increased pain, and separation of wound edges suggest wound dehiscence, a potential postoperative complication.

A 40-year-old patient underwent appendectomy. On postoperative day four, the patient suddenly reports severe abdominal pain, vomiting, and the sensation of “something giving way” in the abdominal incision area. What complication should the nurse suspect?

The sudden onset of severe abdominal pain, vomiting, and the sensation of something giving way are indicative of evisceration, a severe complication involving the protrusion of abdominal organs through the wound opening.

A 55-year-old patient had a hip replacement surgery. On postoperative day six, the patient’s surgical incision site starts to open, revealing underlying tissues. There is no evidence of infection. What is the priority nursing action?

For a patient with a wound opening and no evidence of infection, the priority is to notify the surgeon to assess the extent of wound dehiscence and determine the appropriate intervention.

A 30-year-old patient underwent abdominal surgery. On postoperative day two, the patient’s wound edges separate, and there is a foul-smelling discharge. Which complication of wound healing is likely occurring?

The foul-smelling discharge along with wound separation suggests the development of an abscess, a localized pocket of infection within the wound.

A 50-year-old patient underwent abdominal surgery two days ago. The patient now presents with the sudden protrusion of abdominal organs through the surgical incision. Which nursing action is the highest priority?

Evisceration, the protrusion of abdominal organs through the incision, is an emergency situation. The highest priority is to notify the surgeon immediately for evaluation and intervention.

A 60-year-old patient with a history of abdominal surgery experiences a sudden “bursting” sensation at the incision site. The nurse observes abdominal organs protruding through the wound. What nursing action should be taken?

In cases of evisceration, it is essential to keep the exposed organs moist by covering them with sterile saline-soaked dressings while waiting for surgical intervention.

A 45-year-old patient who had abdominal surgery develops evisceration. The nurse notices that the abdominal contents are covered in a sterile, moist dressing. What should the nurse do next?

Even if the organs are covered with a moist dressing, evisceration requires immediate surgical intervention. The nurse should promptly notify the surgeon for evaluation and management.

A 55-year-old patient with a recent abdominal surgery experiences evisceration. The nurse observes that the abdominal contents are exposed and dry. What should be the immediate nursing action?

If evisceration occurs with dry and exposed organs, the immediate nursing action is to prepare for immediate surgical intervention to prevent infection and complications.

A 70-year-old patient experiences evisceration after abdominal surgery. The nurse observes that the abdominal organs are protruding and covered with a sterile, moist dressing. What nursing action should be taken?

If evisceration is covered with a sterile, moist dressing, the nurse should continue to monitor the patient’s condition and document findings while awaiting surgical evaluation.

A 65-year-old patient is admitted with a diagnosis of acute renal failure. The patient’s laboratory results indicate elevated serum creatinine and decreased urine output. Which nursing intervention is the highest priority?

In acute renal failure with elevated creatinine and decreased urine output, the highest priority is to initiate CRRT to support renal function and remove waste products from the blood.

A 50-year-old patient with a history of hypertension and diabetes is at risk for acute renal failure. Which assessment finding should the nurse prioritize in this patient?

In a patient at risk for acute renal failure, the nurse should prioritize monitoring urine output and creatinine levels as they are indicators of renal function.

A 40-year-old patient is diagnosed with prerenal acute renal failure. Which intervention should the nurse implement first?

In prerenal acute renal failure, the nurse should first identify and correct the underlying cause, which could be related to reduced blood flow to the kidneys.

A 55-year-old patient is receiving intravenous (IV) fluids and medications. The nurse notes decreased urine output and elevated creatinine levels. What action should the nurse take?

In a patient with decreased urine output and elevated creatinine while receiving IV fluids and medications, the nurse should closely monitor the patient’s condition and notify the healthcare provider if needed.

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NCLEX QBank

A 30-year-old patient with acute renal failure is prescribed a low-protein diet. What is the rationale for this dietary restriction?