The nurse has been asked to prepare an intervention plan for a client, age 70, admitted for treatment of renal calculi. He complains of frequent pain due to increased pressure in the renal pelvis and is frightened of the excruciating pain. Which of the ff measures can the nurse include in the client's nursing care plan? Choose all that apply

Correct Answer: B

Rationale: In this scenario, option B, which is to encourage ambulation and liberal fluid intake, is the correct choice for the nursing care plan for the client with renal calculi. Encouraging ambulation helps promote movement of the stones within the urinary tract, potentially aiding in their passage and reducing pain. Liberal fluid intake is essential to help flush out the stones and prevent further formation. Option A, administering nephrotoxic drugs, is incorrect as these drugs can further harm the kidneys, exacerbating the condition. Option C, observing aseptic principles when changing intake, is not directly related to managing renal calculi pain. Option D, providing a comfortable position, is beneficial for overall comfort but does not address the specific issue of renal calculi pain and pressure. Educationally, understanding the rationale behind each intervention is crucial for nurses to provide safe and effective care. By selecting appropriate interventions based on pathophysiology and evidence-based practice, nurses can optimize outcomes for their patients with renal calculi.

Correct Answer: D

Rationale: Calcium gluconate is administered intravenously in the setting of severe hyperkalemia to antagonize the effects of potassium on the heart. Hyperkalemia can lead to dangerous cardiac arrhythmias due to the changes in membrane potential of cardiac cells caused by increased extracellular potassium levels. Administration of calcium gluconate helps stabilize the cardiac cell membrane potential, protecting against the risk of life-threatening arrhythmias. It doesn't provide an immediate decrease in serum potassium levels (Choice A) or prevent transient renal failure (TRF) (Choice B). Therefore, the correct answer is D, as calcium gluconate primarily acts to counteract the effects of hyperkalemia on the heart.

Correct Answer: A

Rationale: The observation that indicates adequate tissue perfusion to vital organs is a urinary output of 30 ml in an hour. Adequate tissue perfusion is essential to ensure that vital organs receive enough blood and oxygen. Monitoring urinary output is a crucial indicator of perfusion status, as it reflects the perfusion of the kidneys. A urinary output of at least 30 ml/hour or more indicates that the kidneys are receiving sufficient blood flow and are able to produce urine, which helps in removing waste products from the body. In this case, a urinary output of 30 ml in an hour suggests adequate tissue perfusion to vital organs. The other options do not directly reflect tissue perfusion to vital organs and may indicate inadequate perfusion or compromised hemodynamic status.

Correct Answer: A

Rationale: Salt tablets should be considered for mild deficits of serum sodium. Salt tablets contain sodium chloride, which helps increase the sodium levels in the body. In cases of mild deficits of serum sodium, also known as hyponatremia, salt tablets can help replenish the sodium levels and correct the electrolyte imbalance. However, for severe deficits of serum magnesium, potassium, or calcium, other specific electrolyte replacement therapies are usually preferred over salt tablets. It is important to consult a healthcare professional for proper diagnosis and treatment of electrolyte imbalances.

Correct Answer: D

Rationale: Keeping the venous access device securely in the vein during a transfusion is important to minimize the risk of localized edema embolism. If the device dislodges and infiltrates into surrounding tissues, it can lead to localized swelling, pain, and potential complications such as tissue damage. Monitoring ensures proper placement and function of the device, reducing the risk of complications related to dislodgment.