You are planning the care for a client for a client with acute kidney injury (AKI). What should you prioritize in the client's plan of care? (Select all that apply)
Optimizing pain
Protecting from falls
Monitoring electrolyte levels
Assessing fluid balance
Promoting infection control
Correct Answer : C,D,E
A. Optimizing pain: While pain management is important in any patient care plan, acute kidney injury typically does not cause significant pain unless associated with another condition such as obstruction or infection. It is not a primary focus unless the patient reports discomfort requiring intervention.
B. Protecting from falls: Fall prevention is a general safety measure but is not a specific priority related to AKI management unless the patient has associated risks like altered mental status, weakness, or dialysis-related hypotension. It is not a primary priority in early AKI care planning.
C. Monitoring electrolyte levels: AKI commonly leads to imbalances in potassium, sodium, calcium, and phosphorus due to impaired renal clearance. Hyperkalemia in particular poses serious cardiac risks, making electrolyte monitoring a top priority to prevent complications such as arrhythmias.
D. Assessing fluid balance: AKI affects the kidneys’ ability to excrete or conserve fluid, resulting in potential fluid overload or dehydration. Accurate intake and output tracking, daily weights, and edema assessment are essential to guide treatment and prevent respiratory or cardiovascular compromise.
E. Promoting infection control: Infection is both a potential cause and a complication of AKI, especially in hospitalized or catheterized patients. Maintaining strict aseptic technique, monitoring for signs of infection, and preventing sepsis are critical components of AKI management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition: Hepatic Encephalopathy
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The client has very high ammonia levels (236 mcg/dL), elevated liver enzymes, and low albumin, all pointing toward hepatic encephalopathy. Additional signs include a history of alcohol abuse, cirrhosis, and altered liver function, which commonly contribute to ammonia accumulation and neurotoxicity.
Actions to Take:
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Administer lactulose: Helps lower serum ammonia by promoting its excretion via the GI tract.
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Assess for asterixis: A classic sign of hepatic encephalopathy characterized by a flapping tremor of the hands.
Parameters to Monitor:
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Neurologic status: To detect changes in mental status or worsening encephalopathy.
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Safety measures: Clients with hepatic encephalopathy are at high risk for confusion, falls, and injury, necessitating close supervision and safety interventions.
Correct Answer is D
Explanation
A. Low-residue diet predisposes to colon diverticula: A low-fiber (low-residue) diet leads to harder stools and increased intraluminal pressure during bowel movements, which promotes the formation of diverticula, especially in the sigmoid colon.
B. Diverticulum may become infected, causing diverticulitis: When fecal material becomes trapped in a diverticulum, it can lead to localized infection and inflammation known as diverticulitis, which may cause pain, fever, or even abscess formation.
C. Ulceration of lining of diverticula caused by fecal material in the diverticula may cause bleeding from the ulcerated diverticulum: Trapped fecal matter can irritate and ulcerate the mucosal lining of diverticula, leading to localized bleeding, which may be seen as rectal bleeding or blood in the stool.
D. Diverticula predispose to colon carcinoma: Diverticulosis is not considered a premalignant condition. Although both conditions may coexist in older adults, the presence of diverticula does not increase the risk of colon cancer.
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