A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?
Hypomagnesemia
Hyperkalemia
Decreased creatinine level
Increased glomerular filtration rate (GFR)
The Correct Answer is B
Choice A Reason: This choice is incorrect because hypomagnesemia is not a common finding in the oliguric phase of acute kidney injury. Hypomagnesemia is a condition in which the serum magnesium level is lower than normal (less than 1.5 mEq/L). It may be caused by various factors such as malnutrition, diarrhea, diuretics, or alcohol abuse. It may cause symptoms such as muscle weakness, tremors, tetany, or cardiac arrhythmias.
Choice B Reason: This choice is correct because hyperkalemia is a common finding in the oliguric phase of acute kidney injury. Hyperkalemia is a condition in which the serum potassium level is higher than normal (more than 5 mEq/L). It may be caused by reduced renal excretion of potassium due to decreased urine output (oliguria). It may cause symptoms such as muscle weakness, paresthesia, bradycardia, or cardiac arrest.
Choice C Reason: This choice is incorrect because decreased creatinine level is not a common finding in the oliguric phase of acute kidney injury. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys and excreted in urine. A normal creatinine level ranges from 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women. In acute kidney injury, creatinine level usually increases due to reduced renal function and impaired clearance of creatinine.
Choice D Reason: This choice is incorrect because increased glomerular filtration rate (GFR) is not a common finding in the oliguric phase of acute kidney injury. GFR is a measure of how well
the kidneys filter blood and remove waste products.
A normal GFR range is 90,to 120 mL/min/1.73 m2. In acute kidney injury, GFR usually decreases due to reduced blood flow,to,the kidneys or damage to the glomeruli, which are the tiny blood vessels that filter blood in the kidneys.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This choice is correct because slow, steady bubbling in the suction control chamber indicates that the suction is working properly and maintaining a negative pressure in the pleural space. The nurse should continue to monitor the client's respiratory status, such as breath sounds, oxygen saturation, and respiratory rate, to assess the effectiveness of the chest drainage system.
Choice B Reason: This choice is incorrect because checking the suction control outlet on the wall is not necessary unless there is no bubbling in the suction control chamber, which would indicate a problem with the suction source or setting. The nurse should ensure that the suction control outlet is set at the prescribed level, usually between 10 and 20 cm H2O.
Choice C Reason: This choice is incorrect because clamping the chest tube is not indicated unless there is a leak in the system or the chest drainage unit needs to be changed. Clamping the chest tube may cause a buildup of air or fluid in the pleural space, which can lead to tension pneumothorax or pleural effusion.
Choice D Reason: This choice is incorrect because checking the tubing connections for leaks is not necessary unless there is continuous bubbling in the water seal chamber, which would indicate an air leak in the system. The nurse should ensure that all tubing connections are tight and secure, and tape any loose connections.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because preparing for mechanical ventilation is not the priority nursing intervention, as it is an invasive and potentially harmful procedure that should be reserved for clients who have severe respiratory failure and cannot maintain adequate oxygenation with noninvasive methods.
Choice B Reason: This is correct because administering oxygen via face mask is the priority nursing intervention, as it is a noninvasive and effective way to improve oxygenation and reduce hypoxemia in a client who has low PaO2 and SaO2. Oxygen therapy can also decrease the workload of the heart and lungs and prevent further complications.
Choice C Reason: This is incorrect because preparing to administer a sedative is not the priority nursing intervention, as it may worsen the client's respiratory status and mask the signs and symptoms of hypoxemia. Sedatives should be used with caution and only after oxygenation has been optimized.
Choice D Reason: This is incorrect because assessing for indications of pulmonary embolism is not the priority nursing intervention, as it is a diagnostic rather than a therapeutic action. Pulmonary embolism is a possible cause of the client's condition, but it does not address the immediate problem of hypoxemia.
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