Correct Answer: B

Rationale: In a client with chronic kidney disease, elevated serum potassium levels (hyperkalemia) are the most concerning finding. Hyperkalemia can lead to life-threatening cardiac dysrhythmias. Monitoring and managing serum potassium levels are crucial in patients with kidney disease to prevent severe complications. While elevated creatinine (
Choice
A) and BUN (
Choice
C) are indicative of impaired kidney function, hyperkalemia poses a more immediate threat to the client's health. Hemoglobin levels (
Choice
D) can be affected by chronic kidney disease but are not as acutely dangerous as severe hyperkalemia.

Correct Answer: A

Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This step helps prevent obstruction in the tubing, maintaining proper urine flow and reducing the risk of infection. Changing the catheter every 72 hours is not recommended unless clinically indicated, as routine changes can increase the risk of introducing pathogens. Cleaning the perineal area with an antiseptic solution is essential for general hygiene but does not directly prevent catheter-related infections. Irrigating the catheter with normal saline every shift is not a standard practice and can introduce microorganisms into the urinary tract, increasing the risk of infection.

Correct Answer: D

Rationale: The most important action for preventing skin impairment in a mobile patient with local nerve damage is to assess for pain during a bath. Assessing pain during a bath helps in evaluating sensory nerve function by checking for touch, pain, heat, cold, and pressure. This assessment is crucial in identifying areas of potential skin breakdown and implementing preventive measures. Inserting an indwelling urinary catheter (
Choice
A) is not directly related to preventing skin impairment in this context. Limiting caloric and protein intake (
Choice
B) is not pertinent to skin impairment prevention for a mobile patient with local nerve damage. While turning the patient every 2 hours (
Choice
C) is a good practice for preventing pressure ulcers, in this case, assessing for pain during a bath is more directly related to preventing skin impairment associated with nerve damage.

Correct Answer: D

Rationale: Acupuncture has been effective for the client previously, supporting continued use.

Correct Answer: B

Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (
Choice
A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (
Choice
C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (
Choice
D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.