A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury (AKI). Which of the following findings should the nurse identify as indicating an increased risk of AKI?

Magnesium 2.5 mEq/L

Serum osmolality 290 mOsm/kg H2O

Blood urea nitrogen (BUN) 20 mg/dL

Serum creatinine 1.8 mg/dL

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect because magnesium 2.5 mEq/L is a normal value and does not indicate an increased risk of AKI. Magnesium is an electrolyte that plays a role in muscle and nerve function, blood pressure regulation, and energy production. The normal range for magnesium is 1.5 to 2.5 mEq/L.

Choice B Reason: This is incorrect because serum osmolality 290 mOsm/kg H2O is a normal value and does not indicate an increased risk of AKI. Serum osmolality is a measure of the concentration of solutes in the blood, such as sodium, glucose, and urea. The normal range for serum osmolality is 275 to 295 mOsm/kg H2O.

Choice C Reason: This is incorrect because blood urea nitrogen (BUN) 20 mg/dL is a normal value and does not indicate an increased risk of AKI. BUN is a measure of the amount of urea, a waste product of protein metabolism, in the blood. The normal range for BUN is 7 to 20 mg/dL.

Choice D Reason: This is correct because serum creatinine 1.8 mg/dL is an elevated value and indicates an increased risk of AKI. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. The normal range for serum creatinine is 0.6 to 1.2 mg/dL for women and 0.7 to 1.3 mg/dL for men. An increase in serum creatinine indicates a decrease in kidney function and glomerular filtration rate (GFR).

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Correct Answer is B

Explanation

Choice A Reason: This choice is incorrect because administering a vasodilator medication may lower the blood pressure and worsen the cerebral perfusion. A vasodilator medication is a drug that relaxes the blood vessels and reduces the resistance to blood ﬂow. It may be used for clients who have hypertension, angina, or heart failure, but it does not help to reduce the intracranial pressure (ICP).

Choice B Reason: This choice is correct because elevating the head of the bed to 30° may help to improve the venous drainage and decrease the ICP. ICP is the pressure exerted by the brain tissue, cerebrospinal ﬂuid (CSF), and blood within the cranial cavity. A normal ICP range is 5 to 15 mm Hg, and an elevated ICP (>20 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, positioning the client in a semi-Fowler's position (30° angle) or high- Fowler's position (60° to 90° angle) can facilitate breathing and prevent further complications.

Choice C Reason: This choice is incorrect because applying a cold compress to the forehead may cause vasoconstriction and increase the ICP. A cold compress is a device that applies cold temperature to a body part to reduce inﬂammation, pain, or swelling. It may be used for clients who have headaches, sprains, or bruises, but it does not help to reduce the ICP.

Choice D Reason: This choice is incorrect because decreasing the oxygen ﬂow rate may cause hypoxia and worsen the cerebral ischemia. Hypoxia is a condition in which the body or a part of it does not receive enough oxygen. It may cause symptoms such as confusion, agitation, or cyanosis. Therefore, providing adequate oxygenation and ventilation is essential to maintain the brain function and prevent further damage.

A. Administer a nitrate antihypertensive. B. Obtain the client's heart rate. C. Assess the client for bladder distention. D. Place the client in a high-Fowler's position.

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because administering a nitrate antihypertensive is not the first action, as it may cause a rapid drop in blood pressure and worsen the client's condition.

Choice B Reason: This is incorrect because obtaining the client's heart rate is not the first action, as it does not address the cause of autonomic dysreﬂexia or relieve the symptoms.

Choice C Reason: This is incorrect because assessing the client for bladder distention is not the first action, as it may take time and delay the treatment of autonomic dysreﬂexia.

Choice D Reason: This is correct because placing the client in a high-Fowler's position is the first action, as it lowers the blood pressure by promoting venous return and reducing cardiac preload.

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A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury (AKI). Which of the following findings should the nurse identify as indicating an increased risk of AKI?

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Naxlex Comprehensive Predictor Exams

Here is the edited text: A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreﬂexia. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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