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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Correct Answer is B

Explanation

A. Acute hemolysis: While it is a complication of dialysis, it typically presents with back pain, dark red urine, and hypotension.

B. Disequilibrium syndrome: Caused by rapid removal of urea during dialysis, leading to cerebral edema. Early signs include nausea, headache, restlessness, and confusion.

C. Septic shock: Presents with hypotension, tachycardia, and signs of infection. Not the most likely with nausea and headache alone.

D. Air embolism: Presents with sudden chest pain, dyspnea, and hypotension; not typically with headache and restlessness alone.

A. Urinary output 25 mL/hr B. Heart rate 122/min C. Pain of 6 on a scale of 0 to 10 D. Difficulty swallowing secretions

Correct Answer is D

Explanation

A. Urinary output 25 mL/hr: This is below normal, but not an immediate airway threat.

B. Heart rate 122/min: Elevated HR is common in burns due to fluid shifts and stress.

C. Pain of 6 on a scale of 0 to 10: Pain is expected but not life-threatening.

D. Difficulty swallowing secretions: Indicates possible airway edema or inhalation injury, which can progress to airway obstruction. This is a medical emergency.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving a hemodialysis treatment. Which of the following complications should the nurse recognize when the client becomes restless and reports nausea and headache?

Correct Answer is B

Explanation

A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?

Correct Answer is D

Explanation

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 is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

A nurse is caring for a client experiencing fatigue secondary to anemia from chronic kidney disease (CKD). How should the nurse respond when the client asks about the cause of the anemia symptoms they are experiencing?

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 assessing a client in the oliguric phase of acute kidney injury (AKI). Which of the following findings should the nurse expect?

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 client has been admitted to a burn intensive care unit with extensive full thickness burns over 36% of the body. After ensuring cardiopulmonary stability, which should be the nurse's highest priority when planning the client's care in the early acute phase of the injury?

A nurse is caring for a client with 45% total body surface area (TBSA) thermal burns. During the emergent, initial phases of burn shock the nurse should closely monitor for which electrolyte imbalance?