Nurs 4 - RN EAQ's - Client Needs: Reduction of Risk Potential & Safety

A client had an abdominal cholecystectomy. The nurse is caring for the client 24 hours after the surgery and notes 150 mL of bile drainage from a client's T-tube. What is the next action the nurse should take? 1 Notify the healthcare provider immediately of the excessive bile drainage. 2 Clamp the tube and drain small amounts of bile every four hours. 3 Check the tube for kinks because the drainage is less than expected. 4 Empty the drainage bag and record the amount on the intake and output record.

3 - Check the tube for kinks because the drainage is less than expected. Bile drainage for the first 24 hours usually is 300 to 400 mL; kinks in the tubing hinder the flow of bile. Drainage of 150 mL is less than expected in the first 24 hours. Clamping the tube is contraindicated during the first 24 hours. Further intervention is necessary because this amount of bile is less than expected.

A nurse is reviewing the laboratory values of a school-aged child with rheumatic heart disease. Which finding does the nurse conclude is related to this condition? 1 Negative C-reactive protein 2 Increased reticulocyte count 3 Positive antistreptolysin titer 4 Low erythrocyte sedimentation rate

3 - Positive antistreptolysin titer A positive antistreptolysin titer is expected with rheumatic fever because of a previous streptococcal infection. A positive, not a negative, C-reactive protein reading is expected with rheumatic heart disease. A positive C-reactive protein reading is indicative of an inflammatory process. An increased reticulocyte count is unexpected. An increased reticulocyte count is usually related to anemia, which stimulates the bone marrow to produce so many red blood cells that more immature blood cells (reticulocytes) enter the circulation. The erythrocyte sedimentation rate is increased, not decreased, with rheumatic heart disease, indicating the presence of an inflammatory process.

After many episodes of otitis media a 3-year-old child is to undergo myringotomy and have tubes implanted surgically. What should the nurse include in the discharge preparation for this family? 1 Keep the child at home for 1 week. 2 Insert earplugs during the child's bath. 3 Apply an ointment to the ear canal daily. 4 Use cotton swabs to clean the inner ears.

2 - Insert earplugs during the child's bath. Water in the ears after myringotomy may be a source of infection. There is no reason that the child cannot be around other children, because there is no infectious process. Applying an ointment to the ear canal daily will clog the ear canal and serves no purpose. Cotton swabs may be used occasionally in the outer ear, but should not be inserted into the ear.

The nurse has provided postoperative teaching to a client who is scheduled for a bilateral herniorrhaphy. Which client statement indicates correct understanding of the teaching? 1 "I will have a nasogastric tube in place." 2 "I should cough and deep breathe regularly." 3 "I will need to be on bed rest for several days." 4 "I will have a portable wound drainage system in place."

2 - "I should cough and deep breathe regularly." After general anesthesia, coughing and breathing deeply expand alveoli and prevent atelectasis. A nasogastric tube is not necessary; the abdomen is not entered, and there should be no interference with peristalsis. Clients can ambulate after recovery from anesthesia. A portable wound drainage system is not necessary.

A client has a fractured mandible that is immobilized with wires. For which life-threatening postoperative problem should the nurse monitor this client? 1 Infection 2 Vomiting 3 Osteomyelitis 4 Bronchospasm

2 - Vomiting Vomiting may result in aspiration of vomitus, because it cannot be expelled; this may cause pneumonia or asphyxia. Infection, osteomyelitis, and bronchospasm generally are not life-threatening problems.

Which are sources of lead the nurse should assess for when providing care to a toddler-age client who is admitted with lead poisoning? Select all that apply. 1 Water 2 Pottery 3 Stained glass 4 Collectable toys 5 Vinyl miniblinds

1 - Water 2 - Pottery 4 - Collectable toys 5 - Vinyl miniblinds Water, pottery, collectable toys, and vinyl miniblinds are all sources of lead that should be included in the nurse's assessment for a toddler-age client who is admitted with lead poisoning. The making of stained glass, not stained glass itself, is a source of lead.

2 - B The client with an A1C % level of less than 7%, fasting plasma glucose > 126 mg/dL, and 2-hour plasma glucose > 200 mg/dL indicates diabetes mellitus. Client B has increased values for A1C %, fasting plasma glucose, and 2-hour plasma glucose. Therefore client B should be treated first. Clients A, C, and D have normal values for diabetes mellitus and, therefore, can be treated after client B.

During a diabetes mellitus campaign, the community nurse is assessing different clients. Which client should be treated first? 1 A 2 B 3 C 4 D

An elderly client undergoing cancer therapy reports diffused redness and large blisters on the skin with evident systemic toxicity. What should be the priority intervention in this client? 1 Discontinue the drug 2 Monitor body temperature 3 Monitor fluid and electrolyte balance 4 Administer topical antibacterial medication

1 - Discontinue the drug Toxic epidermal necrolysis (TEN) is a rare acute drug reaction that manifests as diffused redness and large blisters on the skin. Elderly clients on chemotherapy are at greater risk for TEN. Therefore the drug should be immediately discontinued to reduce further damage to the skin. Monitoring the body temperature is not a priority intervention in this client. The client should be monitored for hypothermia and fluid and electrolyte balance to provide systemic support and prevent secondary infections. Topical antibacterial drugs are administered to suppress the bacterial growth until healing occurs.

How should the nurse make the bed of a client who is in the acute phase after a myocardial infarction? 1 Replace the top linen and only the necessary bottom linen. 2 Lift the client from side to side while changing the bed linen. 3 Change the linen from top to bottom without lowering the head of the bed. 4 Slide the client onto a stretcher to remake the bed and then slide the client back to the bed.

1 - Replace the top linen and only the necessary bottom linen. Until a client's condition has reached some degree of stability after a myocardial infarction, routine activities such as changing sheets are avoided so that the client's movements will be minimized and the cardiac workload reduced. Lifting the client from side to side while changing the bed linen is contraindicated because it increases oxygen consumption and cardiac workload; also, it may strain the health team members who are lifting the client. Changing all the linen causes unnecessary movement, which increases oxygen demand and makes the heart work harder. Any activity is counterproductive to rest; rest must take precedence so that the cardiac workload is reduced.

What are the primary nursing interventions when a client is receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply. 1 Restricting visitors 2 Limiting fluid intake 3 Preparing for a precipitate birth 4 Maintaining a quiet environment 5 Keeping magnesium gluconate at the bedside

1 - Restricting visitors 4 - Maintaining a quiet environment Visitors should be limited to significant others to reduce excessive stimuli that could precipitate a seizure. A quiet room helps reduce stimuli and therefore the risk of seizures. Fluid intake should not be restricted. A precipitous birth is not a usual side effect of magnesium sulfate therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be readily available if signs of toxicity appear.

A client who had a laryngectomy for cancer of the larynx is being transferred from the postanesthesia care unit to a surgical unit. Which is the most important equipment that the nurse should place in the client's room? 1 Suction supplies 2 Writing materials 3 Tracheostomy set 4 Incentive spirometer

1 - Suction supplies Suction equipment is the priority. Respiratory complications can occur after a laryngectomy is performed because of the production of excessive secretions, edema of the glottis, or injury to the recurrent laryngeal nerve. Also, after a laryngectomy the client will be unable to cough effectively to raise secretions. Although writing supplies along with a picture board are helpful for promoting communication, they are not the priority. A tracheostomy set is unnecessary. When a laryngectomy is performed a permanent stoma in the trachea is surgically created, and a laryngectomy tube is in place. An additional sterile laryngectomy tube and obturator should be kept at the bedside. A client with a tracheal stoma cannot use an incentive spirometer.

There has been a fire in a healthcare facility. How should the nurse respond to the situation? Select all that apply. 1 The nurse should move bedridden clients from the affected area. 2 The nurse should direct ambulatory clients to walk to a safe location. 3 The nurse should keep all clients hooked up to oxygen. 4 The nurse should seek to contain the fire by closing the doors and the windows. 5 The nurse should ask other hospital workers only to help push the clients in wheelchairs.

1 - The nurse should move bedridden clients from the affected area. 2 - The nurse should direct ambulatory clients to walk to a safe location. 4 - The nurse should seek to contain the fire by closing the doors and the windows. In the case of a fire in a healthcare facility, the nurse should move bedridden clients from the affected area with the help of wheelchairs or stretchers. The nurse should also direct ambulatory clients to walk to a safe location. The nurse can help to contain the fire by closing the doors and the windows and using an ABC extinguisher. The nurse should only discontinue oxygen for clients who can breathe on their own. The nurse should ask the ambulatory clients, not just other hospital workers, to help push clients in wheelchairs if possible.

A client is transferred to the postpartum care unit 1 hour after a spontaneous vaginal delivery. On assessment, the nurse finds the fundus at U-1 and firm and the pad saturated with blood. The pad is changed and reassessed 15 minutes later and again found saturated with blood. The fundus remains at U-1, midline and firm. Place the interventions in order of priority. 1. Taking vital signs 2. Assessing the episiotomy 3. Calling the primary healthcare provider 4. Weighing pads to measure blood loss 5. Assessing the client for a hematoma

1. - Assessing the episiotomy 2. - Assessing the client for a hematoma 3. - Weighing pads to measure blood loss 4. - Taking vital signs 5. - Calling the primary healthcare provider It is important for the nurse to gather assessment data before calling the primary healthcare provider. The nurse should first check the episiotomy and perineal area for active bleeding. The nurse then assesses the client for the presence of a hematoma; where there has been bleeding and now there is a large collection of blood. Next, the nurse should weigh the blood soaked pads to estimate actual blood loss (1 g of pad weight is equal to 1 mL of blood). Finally, the nurse obtains vital signs to assess the net effect of the blood loss in preparation for calling the healthcare provider. The primary healthcare provider should evaluate the client to determine if there is a laceration or if placental fragments or other problems are present. Because the fundus is firm at U-1 and midline, uterine atony would not be suspected.

An individual with a history of verbal and physical abuse of others is beginning to demonstrate aggressive behavior toward a visitor. Place the following nursing interventions in the appropriate order to best ensure milieu safety. 1. Suggesting to the client, "Walk with me to your room." 2. Calmly addressing the individual by name to redirect the client's attention 3. Explaining that the client will be placed in seclusion if the aggressive behavior continues 4. Reassuring the client that the staff will help control the aggressiveness if the client is unable to do so 5. Firmly stating that aggressive behavior like this cannot be tolerated because "someone may get hurt"

1. - Calmly addressing the individual by name to redirect the client's attention 2. - Suggesting to the client, "Walk with me to your room." 3. - Firmly stating that aggressive behavior like this cannot be tolerated because "someone may get hurt" 4. - Explaining that the client will be placed in seclusion if the aggressive behavior continues 5. - Reassuring the client that the staff will help control the aggressiveness if the client is unable to do so The initial action is to redirect the client's attention. The second action is to remove the client to a safe low-stimulus environment. The third action is to set limits by explaining why the behavior cannot be tolerated. The fourth action is to describe the outcome of not complying. Finally the client must be assured that if the client is unable to control the behavior, staff will help do so.

The student nurse provides follow-up care instructions to a client who recently underwent a biopsy procedure. Which statement of the student nurse requires correction? 1 "Report any redness or excessive drainage." 2 "Avoid using tap water to remove dried blood." 3 "Clean the site daily after the dressing is removed." 4 "Keep the dressing dry and in place for at least 8 hours."

2 - "Avoid using tap water to remove dried blood." After removal of the dressing, the site may be cleaned using tap water or saline. The client should report any redness or excessive drainage through the site. The site should be regularly cleaned after the dressing is removed. A dry dressing should be kept on the site for at least 8 hours.

A registered nurse is evaluating the statements of a client after teaching the client measures to decrease the risk for antibiotic-resistant infections. Which statements made by the client indicate a need for more education? Select all that apply. 1 "I should wash my hands frequently." 2 "I should skip doses when I am completely well." 3 "I should avoid taking antibiotics to treat the common cold." 4 "I should save unfinished antibiotics for later emergency use." 5 "I should avoid taking antibiotics without asking the physician."

2 - "I should skip doses when I am completely well." 4 - "I should save unfinished antibiotics for later emergency use." Antibiotics should not be stopped even if the client is feeling better. Skipping doses may allow antibiotic-resistant bacteria to develop. Antibiotics should not be saved for later emergency use because old antibiotics can lose their effectiveness and in some cases can even be fatal if taken. Hand washing is necessary to prevent infections. Antibiotics are effective against bacterial infections but not viruses, which cause the common cold. Antibiotics should be taken only after asking the physician.

The nurse reviews the blood test results of a client at 24 weeks' gestation. Which finding should be reported to the healthcare provider? 1 Platelets: 230,000 mm3 (230 × 109/L) 2 Hemoglobin: 10.8 g/dL (108 mmol/L) 3 Fasting blood glucose: 90 mg/dL (4.2 mmol/L) 4 White blood cell count: 10,000 mm3 (10 × 109/L)

2 - Hemoglobin: 10.8 g/dL (108 mmol/L) The hemoglobin level of a healthy individual is 12 to 16 g/dL (120 to 160 mmol/L). During pregnancy it may decrease as a result of an increased blood volume, especially during the second trimester. The hemodilution is greater than a concomitant increase in RBC production, causing physiological anemia. If the hemoglobin decreases to less than 11 g/dL (110 mmol/L), anemia, probably due to a deficiency of iron or folic acid, is diagnosed. Iron supplementation may need to be increased. The expected platelet level is 150,000 to 400,000 mm3 (150 × 109/L to 400 × 109/L). There should be no significant change in this level throughout pregnancy. The expected fasting blood glucose is 70 to 105 mg/dL (3.9 to 5.8 mmol/L); it begins to rise in the second trimester and peaks in the third trimester.

The head nurse of the emergency department (ED) is assigning duties to volunteer nurses to care for a group of clients injured in a mass casualty situation. Which assignments are appropriate in this situation? Select all that apply. 1 The general staff nurse should organize nursing services. 2 The trauma nurse manager should organize ancillary services. 3 The medical-surgical nurse should recommend clients for discharge. 4 The ED nurse leader should direct the ancillary departments to deliver supplies. 5 The hospital nurse leader should identify clients who can be transferred out of the unit.

2 - The trauma nurse manager should organize ancillary services. 3 - The medical-surgical nurse should recommend clients for discharge. 4 - The ED nurse leader should direct the ancillary departments to deliver supplies. While caring for clients after a disaster, the trauma nurse manager should help in organizing ancillary services to meet client needs. The medical-surgical nurse should collaborate with the primary healthcare provider in recommending clients for discharge to free inpatient beds. The ED nurse leader should direct the ancillary departments to deliver supplies to meet service needs. The general staff nurse should organize nursing services to provide care for stable emergency department clients. The hospital nurse leader should direct the ancillary departments to deliver supplies, medications, food, instrument trays, and personnel to meet service needs.

A 3-week-old infant has surgery for esophageal atresia. What is the immediate postoperative nursing care priority for this infant? 1 Giving the oral feedings slowly 2 Reporting vomiting to the practitioner 3 Checking the patency of the nasogastric tube 4 Monitoring the child for signs of infection at the incision site

3 - Checking the patency of the nasogastric tube A nasogastric tube is used after surgery to decompress the stomach and limit tension on the suture line. As another means of limiting pressure on the suture line, oral feedings should not be implemented in the immediate postoperative period when the nasogastric tube is in place. Vomiting indicates obstruction of the nasogastric tube; this is why the initial action should be to check the patency of the tube. It is too soon for signs of infection to occur.

A 2-year-old child is admitted with multiple fractures and bruises, and abuse is suspected. Which nursing assessment findings support this suspicion? Select all that apply. 1 Bedwetting 2 Thumb-sucking 3 Difficulty consoling 4 Underdevelopment for age 5 Demands for physical closeness

3 - Difficulty consoling 4 - Underdevelopment for age Abused children may be difficult to console because they have not had positive past interpersonal experiences. Failure to thrive is often seen in abused children. It results from emotional stress, as well as from neglect of physical needs. The task of nighttime bladder training may not be completed until 4 or 5 years of age, and sometimes even later. Thumb-sucking is not noteworthy because many children, not just those who are abused, continue to suck their thumbs for several years. Abused children do not seek physical closeness because their needs for comfort have not been met in the past.

A nurse on the high-risk unit assesses a client admitted with severe preeclampsia. The client has audible crackles in the lower left lobe, slight blurring of vision in the right eye, generalized facial edema, and epigastric discomfort. Which clinical manifestation indicates the potential for a seizure? 1 Audible crackles 2 Blurring of vision 3 Epigastric discomfort 4 Generalized facial edema

3 - Epigastric discomfort Epigastric discomfort suggests liver edema; it is an ominous symptom that indicates an impending seizure. Audible crackles indicate pulmonary edema, but although they are a sign of severe preeclampsia they are not as definitive as epigastric pain. Blurred vision is a sign of retinal edema; although it is a sign of severe preeclampsia it is not as definitive as epigastric pain. Although generalized facial edema is an indication of severe preeclampsia, it is not as definitive as epigastric pain.

The registered nurse is teaching a student nurse about the general principles to be followed while assessing skin lesions. Which statement made by the student nurse indicates the need for further teaching? 1 "I should use the metric system while taking measurements." 2 "I should assess systematically and proceed from head to toe." 3 "I should use appropriate terminology and nomenclature when documenting." 4 "I should perform a lesion-specific examination and then a general inspection."

4 - "I should perform a lesion-specific examination and then a general inspection." During a physical examination, there are some general principles to be followed when assessing skin lesions. General examination is performed prior to a lesion-specific examination. The metric system is used for taking measurements of the lesions. Examination is done systematically from head to toe. Appropriate terminology and nomenclature should be used for reporting and documenting.

The nurse is providing discharge teaching to a client with acquired immunodeficiency syndrome (AIDS) whose white blood cell count (WBC) is low. Which statement indicates a need for further education? Select all that apply. 1 "My roommate will take care of our cat's litter box." 2 "I will rinse my toothbrush in bleach once a week." 3 "I will use a different cup every time I have a drink." 4 "I will eat at least one piece of fresh fruit every day." 5 "I will walk at the mall twice a week to keep up my strength." 6 "I will wash my hands thoroughly after shaking hands with anyone."

4 - "I will eat at least one piece of fresh fruit every day." 5 - "I will walk at the mall twice a week to keep up my strength." When a client with AIDS has a low WBC, it is necessary to avoid possible sources of infection. Raw fruit and vegetables should be avoided, as should large gatherings of people who might be ill. When the WBC is low, the client should avoid changing the litter box, and cups and glasses should not be reused. The client should rinse the toothbrush in bleach weekly and then rinse out the bleach with hot water. Hands should be washed with an antimicrobial soap before eating and drinking, after touching a pet, after using the toilet, and after shaking hands with anyone.

What is the difference between risk nursing diagnoses and actual nursing diagnoses? 1 Actual nursing diagnoses have related factors; risk nursing diagnoses do not have related factors. 2 Actual nursing diagnoses are present in NANDA-I classification; risk nursing diagnoses are absent in NANDA-I classification. 3 Actual nursing diagnoses are associated with environmental and physiological factors; risk nursing diagnoses are not associated with these factors. 4 Actual nursing diagnoses are least likely to be established in a vulnerable population; risk nursing diagnoses are established in vulnerable population.

1 - Actual nursing diagnoses have related factors; risk nursing diagnoses do not have related factors. Actual nursing diagnoses have related factors that show a causality relationship between the diagnosis and the etiology. Risk nursing diagnoses have a risk factor which may predispose a client to a disease. Both the types of diagnoses are mentioned in the NANDA-I classification. Both types of diagnoses may have associations with environmental and physiological factors. Both types of diagnoses can be established in vulnerable population.

A nurse is caring for an 11-year-old child with type 1 diabetes. Two hours after breakfast the child becomes pale, diaphoretic, and shaky. What action should the nurse take? 1 Notifying the practitioner 2 Administering supplemental insulin 3 Obtaining a current blood glucose level 4 Giving orange juice with a slice of bread

3 - Obtaining a current blood glucose level Although the child is demonstrating signs and symptoms of hypoglycemia, the blood glucose level must be determined before therapy can be instituted. The practitioner should be notified after the blood glucose level is known and after emergency intervention has been implemented, if required. Administering insulin will exacerbate the hypoglycemia and endanger the child. If hypoglycemia is present, low-fat milk is preferred as a simple carbohydrate, and a slice of bread with peanut butter provides complex carbohydrates.

A client is admitted to the hospital with a tentative diagnosis of urinary retention related to benign prostatic hyperplasia. The primary healthcare provider notes a secondary diagnosis of delirium related to urosepsis and prescribes the insertion of an indwelling urinary retention catheter. Which nursing action is most important at this time? 1 Secure a prescription for wrist restraints. 2 Orient the client to time, place, and person. 3 Involve family members in the client's care. 4 Determine whether any unsafe behavior patterns exist.

4 - Determine whether any unsafe behavior patterns exist. The nurse should determine whether the client is a danger to self or others before planning and implementing care. No pattern of unsafe behavior has been identified requiring the use of wrist restraints. Pulling on the retention catheter is a concern because this may cause an injury. However, less restrictive alternatives to wrist restraints should be tried first. A restraint is used as a last resort. Orienting a client to time, place, and person is appropriate for a client with delirium; however, this will not protect the client from attempting to pull out the urinary catheter or from engaging in other unsafe behaviors. Although family members should be involved in a client's care, it is not the responsibility of a family member to assess a client or protect a client from injury.

A client had thoracic surgery. The nurse should monitor for which clinical manifestations that may indicate acute pulmonary edema? Select all that apply. 1 Crackles 2 Cyanosis 3 Chest pain 4 Bradypnea 5 Frothy sputum

1 - Crackles 2 - Cyanosis 5 - Frothy sputum Crackles signify fluid in the alveoli because of increased capillary permeability associated with pulmonary edema. Cyanosis is evidence of inadequate oxygenation. Frothy sputum results because of the large amount of fluid in the lungs; it may or may not be blood tinged. Chest pain is not a symptom of acute pulmonary edema; this is associated with a pneumothorax. Dyspnea, not bradypnea, is associated with pulmonary edema.

A nurse is caring for a preschool-age child with leukemia who is undergoing chemotherapy and may have a fever. What factors should the nurse consider before taking this child's temperature? Select all that apply. 1 Skin sensor temperatures are not accurate past infancy. 2 Rectal temperatures are too upsetting for this age group. 3 Oral temperatures are accurate in children with leukemia. 4 Rectal temperatures are avoided to reduce the risk of rectal trauma. 5 Tympanic temperatures are not accurate when a fever is suspected.

2 - Rectal temperatures are too upsetting for this age group. 3 - Oral temperatures are accurate in children with leukemia. 4 - Rectal temperatures are avoided to reduce the risk of rectal trauma. Rectal temperatures are considered invasive by the preschool-age child; however, it is not the only reason to avoid taking this child's temperature rectally. Oral temperatures are accurate, as long as the child can hold the thermometer in the mouth correctly. Chemotherapy causes alterations in mucous membranes; a rectal thermometer could damage delicate rectal tissue. A skin sensor is accurate as long as the instructions provided by the product are followed. Tympanic temperatures are accurate as long as proper technique is used.

A thallium scan is scheduled for a client who had a myocardial infarction. What should the nurse explain to the client regarding the reason the scan has been prescribed? 1 That it will monitor the mitral and aortic valves 2 That it establishes the viability of myocardial muscle 3 That it can visualize the ventricular systole and diastole 4 That it will determine the adequacy of electrical conductivity

2 - That it establishes the viability of myocardial muscle A thallium scan is a radionuclear study that establishes the viability of myocardial tissue; necrotic or scar tissue does not extract the thallium isotope. Monitoring the mitral and aortic valves and visualizing the ventricular systole and diastole is available from cardiac catheterization with angiography. A 12-lead electrocardiogram determines the adequacy of electrical conductivity.

While reviewing the laboratory results of a client in an acute care setting, the nurse finds urine output of 250 mL in 24 hours, blood osmolality of 310 milliosmoles per kg, and a systolic blood pressure of 90 mm Hg. What is the priority nursing intervention in this situation? 1 Consider it as a normal finding. 2 Advise the client to drink 2 to 3 L of water daily. 3 Assess the creatinine and blood urea nitrogen (BUN) levels. 4 Request an increase in the intravenous fluid rate from the healthcare provider.

4 - Request an increase in the intravenous fluid rate from the healthcare provider. Normal urine output is in the range of 600 to 2500 mL per 24 hour and normal blood osmolality is in the range of 275 to 295 milliosmoles per kilogram. The normal systolic pressure is 120 mm Hg. The client's medical record indicates an abnormal urine output of 250 mL in the past 24 hours, blood osmolality of 310 milliosmoles per kg, and systolic blood pressure of 90 mm Hg, which indicate severe volume depletion. Therefore the priority nursing intervention is requesting an increase in the intravenous fluid rate from the healthcare provider to prevent permanent kidney damage. A healthy individual is advised to drink 2 to 3 L of water daily. The client's creatinine and blood urea nitrogen (BUN) level are assessed to detect kidney function, but only after the client is made stable.