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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Hemorrhage: Hemorrhage leads to significant blood loss, resulting in decreased blood volume and reduced renal perfusion, which is a common cause of prerenal acute kidney injury (AKI).

B. Cirrhosis: Cirrhosis can cause systemic vasodilation and reduced effective circulating volume, leading to decreased renal blood flow and prerenal failure due to impaired kidney perfusion.

C. Kidney disease: Kidney disease itself is an intrinsic (renal) cause of kidney failure, involving direct damage to the kidney tissue, rather than prerenal failure caused by decreased perfusion.

D. Narrowing of the blood vessels leading to the kidneys: Renal artery stenosis reduces blood flow to the kidneys, causing prerenal failure by impairing kidney perfusion despite adequate circulating volume.

A. Heart rate: 92/min B. Respiratory rate: 20/min C. Oxygen saturation: 96% on room air D. reports extreme fatigue. E. Client rates pain as 3 on a 0 to 10 pain scale following administration of pain medication 30 min ago. F. Respirations even, unlabored. Chest clear on auscultation. G. Bowel sounds hypoactive in all four quadrants. H. Client vomiting brown liquid and reports continuing nausea. I. Reports passing flatus. Urinating without difficulty, urine is clear yellow.

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

Explanation

Heart rate: 92/min: Improved from 109/min on Day 1, showing better autonomic control.
A heart rate within normal range indicates reduced stress or inflammation. This suggests pain management and fluid status have improved.
Respiratory rate: 20/min: Improved from 26/min, now within normal limits. This reflects decreased respiratory effort and better oxygenation. The labored breathing on Day 1 has also resolved.
Oxygen saturation: 96% on room air: Increased from 93% on Day 1, indicating improved gas exchange. No supplemental oxygen was required, suggesting stable pulmonary function.
This is a positive sign especially given the initial diminished breath sounds.
Client rates pain as 3/10 after medication: The pain is down from 8/10 on Day 1, showing effective analgesia. Pain control improves patient comfort and respiratory status. The pain was likely contributing to tachypnea and lethargy on Day 1.
Respirations even and unlabored; chest clear on auscultation: Improved from "rapid, labored" with "diminished" breath sounds on day 1 which suggests resolution of respiratory compromise and pain-related restriction. Likely associated with improved oxygen saturation and decreased fatigue..
Passing flatus: This indicates return of peristalsis and some bowel activity. These findings were not present on Day 1, showing progress. Flatus passage often precedes return to full bowel function.
Urinating without difficulty; urine clear yellow: These findings indicate stable renal function, no hematuria or concentration issues. The findings were maintained across both days, with no signs of obstruction or dehydration which uggests effective fluid balance and kidney perfusion.

Rationale for Incorrect Findings:

Bowel sounds hypoactive in all quadrants: No change from Day 1, suggests slow GI recovery. Hypoactivity may reflect paralytic ileus or continued inflammation.
Despite passage of flatus, bowel function remains impaired.
Client vomiting brown liquid and reports continuing nausea: This is a new symptom on Day 2, worsening GI symptoms despite earlier improvement. Brown emesis may suggest delayed gastric emptying or possible GI bleeding.
Reports extreme fatigue: Fatigue is more severe than Day 1's lethargy and may reflect nutritional deficits, systemic inflammation, or sleep disruption. Despite improved pain and respiratory status, overall energy is low.

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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)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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