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A patient is admitted with acute kidney injury and the following assessment cues:

K: 6.9 (3.5-5.0)

Cr: 3.2 (0.6-1.2)

Urine: 300 mL/24 hrs

What priority actions should be anticipated by the nurse? Select all that apply.

Place the patient on a cardiac monitor immediately.

Weigh the patient immediately.

Anticipate a fluid bolus.

Ask to have the laboratory redraw the blood specimen.

Anticipate an order for a diuretic.

Prepare to administer IV insulin and dextrose as ordered.

Administer Kayexalate (sodium polystyrene) as ordered.

Answer and Explanation

Correct Answer : A

Choice A reason: Placing the patient on a cardiac monitor immediately is crucial due to the elevated potassium level (6.9), which can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and prompt management of any arrhythmias that may occur.

Choice B reason: Weighing the patient immediately is important for assessing fluid status and for calculating appropriate medication dosages. In patients with acute kidney injury, monitoring fluid balance is critical to prevent fluid overload and ensure accurate treatment.

Choice C reason: Anticipating a fluid bolus is not appropriate for this patient. Fluid overload can exacerbate kidney injury and worsen the patient's condition. Fluid management should be carefully tailored based on the patient's overall clinical status and needs.

Choice D reason: Asking to have the laboratory redraw the blood specimen is unnecessary if the initial results are accurate and timely. The focus should be on addressing the critical findings, such as hyperkalemia, rather than retesting.

Choice E reason: Anticipating an order for a diuretic might be considered, but it is not the immediate priority. Diuretics may be useful in managing fluid overload but do not directly address the immediate life-threatening hyperkalemia.

Choice F reason: Preparing to administer IV insulin and dextrose as ordered is essential for treating hyperkalemia. Insulin helps to shift potassium into cells, thereby lowering the serum potassium level. Dextrose is given concurrently to prevent hypoglycemia caused by insulin administration.

Choice G reason: Administering Kayexalate (sodium polystyrene) as ordered is important for removing excess potassium from the body. Kayexalate works by exchanging sodium for potassium in the intestines, promoting the excretion of potassium in the stool.

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Correct Answer is D

Explanation

Choice A reason: Hypokalemia, or low potassium levels, is not typically expected in clients with extensive burn injuries. In fact, during the acute phase of burn injury, hyperkalemia is more common due to the release of potassium from damaged cells and the impairment of kidney function.

Choice B reason: Metabolic alkalosis is not a common finding in clients with extensive burns. Instead, metabolic acidosis is more likely due to the increased production of lactic acid from tissue hypoxia and impaired perfusion. Burn injuries can lead to significant fluid and electrolyte shifts, but metabolic alkalosis is not the usual result.

Choice C reason: Low hemoglobin can occur in burn patients due to fluid shifts and the loss of red blood cells from the injury itself. However, it is not the most characteristic laboratory finding associated with extensive burns compared to hyperkalemia.

Choice D reason: Hyperkalemia is the expected laboratory result in clients with extensive burn injuries. Burns cause massive cell destruction, leading to the release of intracellular potassium into the bloodstream. Additionally, impaired kidney function in the acute phase can further contribute to elevated potassium levels, making hyperkalemia a common and critical concern in burn patients.

A. Fever. B. Gray-blue discoloration of the flank or umbilical area. C. Hypertension. D. Decreased amylase level. E. Nausea and vomiting. F. Severe abdominal pain.

Correct Answer is ["A","B","E","F"]

Explanation

Choice A reason: Fever is a common sign of acute pancreatitis and indicates an inflammatory response. Inflammation of the pancreas can trigger the release of cytokines and other inflammatory mediators, leading to an elevated body temperature. This is a common symptom observed in many cases of acute pancreatitis and suggests an ongoing inflammatory process.

Choice B reason: Gray-blue discoloration of the flank or umbilical area, also known as Grey Turner's sign and Cullen's sign respectively, indicates bleeding and severe inflammation within the pancreas. These signs are indicative of retroperitoneal hemorrhage or pancreatic necrosis, which are severe complications of acute pancreatitis. The presence of such discoloration is a significant finding that suggests a more serious form of the condition.

Choice C reason: Hypertension is not typically associated with acute pancreatitis. In fact, patients with acute pancreatitis are more likely to experience hypotension due to fluid shifts, inflammatory responses, and potential hemorrhage. Monitoring blood pressure is important in these patients to manage any potential complications.

Choice D reason: Decreased amylase level is not an expected finding in acute pancreatitis. Typically, acute pancreatitis is associated with elevated levels of pancreatic enzymes such as amylase and lipase due to inflammation and damage to the pancreatic cells, which release these enzymes into the bloodstream.

Choice E reason: Nausea and vomiting are common symptoms in acute pancreatitis. The inflammation of the pancreas and the associated pain can stimulate the vomiting center in the brain and lead to nausea and vomiting. These symptoms are often severe and can significantly affect the patient's comfort and hydration status.

Choice F reason: Severe abdominal pain is one of the hallmark signs of acute pancreatitis. The pain is typically located in the upper abdomen and may radiate to the back. It is often described as constant and severe, and can be exacerbated by eating or lying flat. Effective pain management is a critical aspect of caring for patients with acute pancreatitis.

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A patient is admitted with acute kidney injury and the following assessment cues: K: 6.9 (3.5-5.0) Cr: 3.2 (0.6-1.2) Urine: 300 mL/24 hrs What priority actions should be anticipated by the nurse? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

Correct Answer is D

Explanation

The emergency department nurse can expect to see which assessment cues in the patient with acute pancreatitis? Select all that apply.

Correct Answer is ["A","B","E","F"]

Explanation

When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

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A nurse cares for a patient who has burn injuries. The patient's wife asks, "When will his high risk for infection decrease?" How would the nurse respond?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

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A patient is admitted with acute kidney injury and the following assessment cues:

K: 6.9 (3.5-5.0)

Cr: 3.2 (0.6-1.2)

Urine: 300 mL/24 hrs

What priority actions should be anticipated by the nurse? Select all that apply.