The nurse is caring for a client who is in the oliguric phase of acute kidney injury (AKI). During this phase of AKI, the nurse might anticipate which of the following findings?

Hyperkalemia

Urine output of 2000 mL in 24 hours

Tachycardia

Tenting of the skin

Answer and Explanation

The Correct Answer is A

Choice A reason: In the oliguric phase of AKI, kidney function is severely impaired, reducing potassium excretion. This leads to hyperkalemia, which disrupts cardiac electrical activity, potentially causing life-threatening arrhythmias or cardiac arrest. Elevated potassium levels are a hallmark of this phase due to decreased glomerular filtration rate and impaired tubular secretion.

Choice B reason: Urine output of 2000 mL in 24 hours indicates polyuria, characteristic of the recovery phase of AKI, not the oliguric phase, where output is typically less than 400 mL/day. High urine output suggests restored renal function, which is not expected in the oliguric phase, where kidneys fail to filter adequately.

Choice C reason: Tachycardia may occur in AKI due to fluid overload causing increased cardiac workload or electrolyte imbalances like hyperkalemia affecting heart rhythm. However, it is a secondary symptom and less specific than hyperkalemia, which directly results from impaired renal excretion and poses a more immediate risk to cardiac function.

Choice D reason: Tenting of the skin indicates dehydration, which may precede AKI but is not typical in the oliguric phase, where fluid retention is more common due to reduced urine output. Fluid overload leads to edema, not dehydration, making skin tenting an unlikely finding in this phase of AKI.

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Correct Answer is C

Explanation

Choice A reason: Renal failure impairs erythropoietin production, a hormone stimulating red blood cell synthesis, leading to anemia, not an increased red blood cell count. Reduced glomerular filtration exacerbates toxin accumulation, further suppressing bone marrow activity, making an elevated red blood cell count unlikely in this condition.

Choice B reason: In renal failure, kidneys fail to excrete potassium, leading to hyperkalemia, not decreased serum potassium. Hyperkalemia can cause cardiac arrhythmias due to altered membrane potentials. A decreased potassium level is more associated with conditions like diuretic use or vomiting, not renal failure.

Choice C reason: Increased serum creatinine is a hallmark of renal failure, as kidneys cannot filter creatinine, a muscle metabolism byproduct. Elevated levels reflect reduced glomerular filtration rate, indicating kidney dysfunction. This is a reliable marker for assessing renal failure severity and progression, making it an expected finding.

Choice D reason: Renal failure typically causes hypocalcemia, not increased serum calcium, due to impaired vitamin D activation and phosphate retention, which binds calcium. Hypercalcemia is rare and may occur in other conditions like hyperparathyroidism, not renal failure, where calcium homeostasis is disrupted by kidney dysfunction.

A. It happens frequently, so just ignore it; they will stop B. Set firm limits and boundaries for the client C. Walk away and have someone else take care of the client D. Tell the client that you are going to report to the director of the unit

Correct Answer is B

Explanation

Choice A reason: Ignoring sexually aggressive behavior is unsafe and unprofessional, as it fails to address potential escalation or harm. Aggression may stem from impulsivity or mental health conditions, requiring intervention to ensure safety and maintain therapeutic boundaries, making this response inadequate and risky in a behavioral health setting.

Choice B reason: Setting firm limits and boundaries establishes clear expectations, reducing inappropriate behavior while maintaining safety. This approach addresses the client’s impulsivity or lack of control, common in mental health disorders, by reinforcing professional conduct and ensuring a therapeutic environment, making it the most effective and safe response.

Choice C reason: Walking away and delegating care avoids addressing the behavior, potentially escalating the client’s aggression or disrupting care continuity. It fails to establish boundaries, which are critical for managing behavioral issues in mental health settings, and may undermine the client’s trust in the therapeutic process, making it inappropriate.

Choice D reason: Reporting to the director without first addressing the behavior skips essential de-escalation steps. While reporting may be needed for persistent issues, immediate boundary-setting is more appropriate to manage aggression, maintain safety, and support therapeutic goals, making this response less effective as an initial action.

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The nurse is caring for a client who is in the oliguric phase of acute kidney injury (AKI). During this phase of AKI, the nurse might anticipate which of the following findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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