A nurse is responsible for screening client’s history for risk factors for possible complications.
Vital signs
BP 188/93
P 80
A nurse is correlating data documented in a client's medical history. The nurse should recognize that which client data indicates risk factors for acute kidney injury? (Select all that apply.)
low serum albumin
Renal Calculi
Hypertension
Hypovolemia
ineffective wound healing
Correct Answer : B,C,D
A. Low serum albumin: While low albumin indicates poor nutrition or liver disease, it's not a direct cause of AKI.
B. Renal Calculi: Can cause obstruction in the urinary tract, leading to post-renal AKI.
C. Hypertension: Chronic high BP damages renal vasculature, increasing AKI risk.
D. Hypovolemia: Decreased perfusion leads to prerenal AKI.
E. Ineffective wound healing: Indicates poor nutrition or infection, but is not a primary AKI risk factor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not escharotomy.
B. "This procedure involves placing the client into a Whirlpool tub and removing the dead tissue.": This describes hydrotherapy or wound debridement.
C. "Dead tissue will be non-surgically removed.": Describes enzymatic or mechanical debridement.
D. "Incisions will be made in the burnt tissues to improve circulation.": Escharotomy relieves pressure caused by tight, burned skin (eschar) to restore blood flow and prevent compartment syndrome.
Correct Answer is C
Explanation
A. A combination of benzodiazepines and topical anesthetics: This is not effective for the deep and constant pain experienced with burns.
B. The use of oral opioids: Absorption may be delayed or unpredictable in critically ill burn clients.
C. A patient-controlled analgesia (PCA) system: PCA provides rapid and individualized control of pain, which is essential in the acute phase.
D. Distraction and relaxation techniques: These are supportive, not primary, strategies for severe pain.
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