A nurse is reinforcing teaching with a client about the oliguric phase of acute kidney injury. Which of the following information should the nurse include in the teaching?

The oliguric phase lasts for 2 days.

The client's urine output is less than 400 mL per 24 hours.

The oliguric phase begins within 1 month of the injury.

The client's BUN and creatinine decreases during this phase.

Answer and Explanation

The Correct Answer is B

A.   The oliguric phase of AKI typically lasts longer than 2 days. It can extend from several days to weeks, depending on the underlying cause and the response to treatment.
B.   During the oliguric phase of AKI, urine output is significantly reduced. Typically, urine output is less than 400 mL per day, but it can vary widely based on the severity of kidney injury and individual factors.
C.   The oliguric phase of AKI usually begins within a few days to a week after the initial injury. It is characterized by a sudden decrease in urine output and may be accompanied by electrolyte imbalances and fluid overload.
D.   During the oliguric phase of AKI, there is typically a buildup of waste products such as blood urea nitrogen (BUN) and creatinine in the blood. These levels rise because the kidneys are unable to effectively filter and excrete waste products. Therefore, BUN and creatinine levels usually increase during the oliguric phase.

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Correct Answer is A

Explanation

A. This is a crucial step to prevent aspiration (the inhalation of oral contents into the lungs). Turning the client on their side helps to facilitate drainage and prevents oral fluids and debris from entering the airway during oral care.
B. Using a stiff toothbrush can be harmful to the gums and oral tissues, especially for clients who are unresponsive and may not be able to indicate discomfort. A soft-bristled toothbrush or moistened gauze is recommended for cleaning the teeth and gums to prevent injury and maintain oral hygiene effectively.
C. Applying petroleum jelly or a similar barrier ointment helps to moisturize and protect the lips from dryness and cracking, which can be common in clients who are unresponsive and may not be able to moisten their lips independently.
D. Using the thumb and index finger to keep the client's mouth open is gentle and effective. This technique allows the nurse to visualize and clean the oral cavity adequately without causing discomfort or injury to the client.

A. A client who has lactose intolerance B. A client who has had a stroke C. A client who has had prolonged diarrhea D. A client who is 4 hr postoperative following a leg amputation under general anesthesia E. A client who has had radiation therapy for head and neck cancer

Correct Answer is ["B","D","E"]

Explanation

A. Lactose intolerance does not directly increase the risk of aspiration. It is a condition where the body cannot easily digest lactose, a type of sugar found in dairy products, leading to gastrointestinal symptoms such as bloating, diarrhea, and gas. Aspiration risk is not typically associated with lactose intolerance.
B. Clients who have had a stroke often experience dysphagia (difficulty swallowing) due to impaired coordination of the muscles involved in swallowing. This dysphagia can lead to food or liquids entering the airway instead of the esophagus, increasing the risk of aspiration.
C. Prolonged diarrhea does not directly increase the risk of aspiration during eating. Diarrhea is a gastrointestinal symptom that typically affects the lower digestive tract and is not directly related to swallowing or aspiration risk.
D. After surgery, especially under general anesthesia, clients may have impaired protective airway reflexes and reduced consciousness level, increasing the risk of aspiration. The recovery phase postoperatively is critical, as clients may not have regained full control of their swallowing reflexes.
E. Radiation therapy in the head and neck region can cause tissue damage, including to the muscles and nerves involved in swallowing. This damage can result in dysphagia and increase the risk of aspiration during eating.

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A nurse is reinforcing teaching with a client about the oliguric phase of acute kidney injury. Which of the following information should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is ["B","D","E"]

Explanation

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