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 C
Explanation
A. Encourage the client to cough and auscultate the lungs again:
This delays necessary intervention and is not appropriate for suspected airway compromise.
B. Document the change and continue to monitor the client's respiratory rate:
Passive monitoring is not safe here given signs of impending respiratory failure.
C. Notify the health care provider and prepare for endotracheal intubation:
Facial burns and decreasing breath sounds suggest airway edema—immediate intubation is critical before complete airway obstruction.
D. Reposition the client in high-Fowler's position and reassess breath sounds:
While positioning helps breathing, it’s not sufficient or timely enough in a rapidly deteriorating airway.
Correct Answer is B
Explanation
A. Draw blood for a CBC: Important, but not the priority.
B. Inspect the mouth for signs of inhalation injuries: Airway assessment is always the priority in facial/chest burns due to the risk of inhalation injury and impending airway compromise.
C. Administer intravenous pain medication: Important, but airway always comes first.
D. Insert an indwelling urinary catheter: Urine output monitoring is important for fluid resuscitation but follows airway stabilization.
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