Your patient with acute kidney injury seems to be urinating more frequently after having a period of reduced urine output. You begin to think they are in the diuretic phase of AKI at this time. What do you want to monitor in this patient during this stage?
Monitor for skin breakdown
Monitor for loose stools
Monitor neurological status
You want to monitor for hypotension
The Correct Answer is D
A. Monitor for skin breakdown is incorrect because while skin care is always important, it is not the priority concern during the diuretic phase of AKI. The main issue in this phase is fluid and electrolyte losses rather than pressure-related skin issues.
B. Monitor for loose stools is incorrect because gastrointestinal issues like diarrhea are not directly associated with the diuretic phase of AKI. Loose stools may occur due to other causes, but they are not a primary concern in this stage.
C. Monitor neurological status is incorrect because although electrolyte imbalances can affect neurological function, the most immediate risk during the diuretic phase is volume depletion and hypotension, which can worsen kidney injury.
D. You want to monitor for hypotension is correct because the diuretic phase of AKI is characterized by high urine output, which can lead to significant fluid and electrolyte losses. This puts the patient at risk for hypovolemia and hypotension, which can compromise renal perfusion and delay recovery. Nursing care during this phase focuses on careful monitoring of blood pressure, fluid status, and electrolytes, and replacing fluids as needed to maintain hemodynamic stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Normal ICP is incorrect because normal intracranial pressure ranges from 5 to 15 mmHgin adults. Values above 20 mmHg are considered elevated, and sustained ICP above 20–25 mmHg is critically highand requires urgent intervention.
B. Mildly elevated ICP is incorrect because ICP of 28 mmHg exceeds mild elevation, which is generally considered 20–25 mmHg. This patient’s ICP is above that range and represents a dangerous level.
C. Critically elevated ICP is correct. An ICP of 28 mmHg indicates critically elevated intracranial pressure, especially when accompanied by low CPP (normal 60–70 mmHg)and hypercapnia (PaCO2 60 mmHg). Hypercapnia causes cerebral vasodilation, further increasing ICP and worsening cerebral perfusion. Immediate interventions are required to reduce ICP, optimize CPP, and prevent secondary brain injury.
Correct Answer is A
Explanation
A. Antibiotics until meningitis can be ruled out is correct because a brain tissue laceration disrupts the protective barriers of the brain, such as the meninges, increasing the risk for infection including meningitis or abscess formation. Prophylactic antibiotics are often administered until infection is ruled out or controlled.
B. Placing patient on anticoagulants is incorrect because anticoagulants increase the risk of bleeding, which can worsen intracranial hemorrhage in patients with brain tissue injury.
C. Encouraging deep breathing and coughing is incorrect because while generally beneficial for pulmonary function, vigorous coughing can increase intracranial pressure (ICP)and worsen brain injury, so it is not routinely encouraged in patients with brain lacerations.
D. Monitoring for peripheral edema is incorrect because edema in the extremities is not a primary concernin managing brain tissue lacerations. The critical focus is neurological status, ICP, and prevention of infection.
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