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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Skin is red, blanches, and weeps: This is consistent with deep partial-thickness burns. These burns damage deeper layers but still allow capillary refill and exudate.

B. Skin has a leathery and dry: This is characteristic of full-thickness (third-degree) burns.

C. Skin is waxy in appearance: A waxy appearance suggests full-thickness burns.

D. Skin is intact, dry, and red in color: This indicates superficial (first-degree) burns like sunburn.

A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area." B. "This procedure involves placing the client into a Whirlpool tub and removing the dead tissue." C. "Dead tissue will be non-surgically removed." D. "Incisions will be made in the burnt tissues to improve circulation."

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.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?

Correct Answer is A

Explanation

A nurse is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

Correct Answer is D

Explanation

A nurse is reviewing the medication record for a client diagnosed with chronic kidney disease (CKD). Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity?

A nurse is triaging multiple clients who arrived in the emergency department from a house fire. The nurse assesses that which client has the highest priority for care?

A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse Implement to ensure proper dialysate exchange?

A nurse is preparing a client for the operating room Exhibits A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following interventions should the nurse include in the plan? (Select all that apply)

A nurse is reviewing laboratory values of a client with chronic renal failure and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

A nurse is caring for a client who is prescribed cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can increase cyclosporine levels to a toxic level?

A nurse is preparing to administer a large dose of prescribed opioid analgesic and light sedation for a dressing change for a client with significant burn injuries. The nurse is aware that which of the following is part of preparing for the opioid analgesic and sedative administration?

A nurse in an emergency room is caring for a client who sustained deep partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?