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When assessing a client with Acute Kidney Injury, which initial nursing assessments should the nurse prioritize? (Select All that Apply.)

Pain level and location

Neurological status and level of consciousness

Gastrointestinal function and bowel sounds

Blood pressure and heart rate

Skin integrity and presence of edema

Psychosocial assessment and support system

Urinary output and color

Nutritional status and dietary preferences

Respiratory status including rate, effort, and oxygen saturation

Answer and Explanation

Correct Answer : B,D,E,G,I

A. Pain is important but not a priority unless the cause of AKI is due to an obstruction.
B. Neurological status is critical because toxin buildup (uremia) can affect cognition and cause confusion or lethargy.
C. GI assessment is less critical in the initial evaluation.
D. Blood pressure and heart rate are essential to assess for fluid volume status and perfusion.
E. Skin integrity and edema give insight into fluid retention, a common issue in AKI.
F. Psychosocial assessment is important but not urgent in the acute setting.
G. Urinary output and color directly reflect kidney function and the effectiveness of perfusion.
H. Nutritional status is relevant but not a top priority during the initial phase of AKI.
I. Respiratory status is prioritized because fluid overload can cause pulmonary edema and respiratory distress.

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Correct Answer is ["B","D"]

Explanation

A: The client's SpO2 is 95%, which is within an acceptable range, so oxygen therapy is not required at this time.
B: The client has a mild fever (37.8°C), and acetaminophen is indicated to help manage fever and improve comfort.
C: There is no indication of bowel obstruction or complications that would require an NG tube for decompression at this time.
D: The wound drain has had no output in 8 hours, which could indicate a blockage or other issue, warranting evaluation by the provider.
E: There is no indication of urinary retention or issues that would necessitate the insertion of a urinary catheter at this time.

A. Hypernatremia B. Hypercalcemia C. Hyperkalemia D. Hypophosphatemia

Correct Answer is C

Explanation

A: Hyponatremia is more common due to fluid retention and dilution.
B: Hypercalcemia is not typically associated with AKI.
C: In AKI, especially prerenal, potassium levels rise due to reduced excretion, placing the client at risk for dysrhythmias.
D: Hyperphosphatemia, not hypophosphatemia, is expected in kidney injury due to impaired phosphate excretion.

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When assessing a client with Acute Kidney Injury, which initial nursing assessments should the nurse prioritize? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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