Practice Question
A nurse was assessing a patient .
Answer Choices:
Rationale:
Potential Condition: Acute Kidney Injury (AKI) ✅
🔷 Rationale:
💥The client was admitted with a myocardial infarction and stent placement but is now showing evidence of renal impairment.
💥The urine output dropped to 100 mL overnight, which is oliguria (less than 0.5 mL/kg/hr).
💥Elevated BUN (26 mg/dL), creatinine (1.9 mg/dL), and reduced GFR (48 mL/min) confirm declining kidney function.
💥Contributing factors include reduced cardiac output (crackles, edema, irregular pulse, tachycardia) leading to poor renal perfusion and acute kidney injury.
💥The metabolic acidosis (pH 7.31, HCO₃ 20) and hyperkalemia (K+ 5.6 mEq/L) further support AKI as the most likely condition.
Priority Nursing Actions:
🔷 Initiate oxygen therapy
💥AKI often occurs secondary to poor perfusion and hypoxemia due to decreased cardiac output.
💥Supplemental oxygen supports tissue oxygenation and helps relieve cardiac workload.
💥Adequate oxygenation also helps maintain kidney perfusion, slowing further damage.
🔷 Obtain a 12-lead electrocardiogram (ECG)
💥The client has potassium of 5.6 mEq/L, which places them at risk for life-threatening dysrhythmias.
💥Irregular peripheral and apical pulses indicate possible arrhythmias already occurring.
💥A 12-lead ECG provides immediate information about potassium-induced changes (peaked T waves, widened QRS) and rhythm disturbances, guiding urgent treatment decisions.
Priority Parameters to Monitor:
🔷 Oxygen saturation
💥Monitoring oxygen saturation ensures the effectiveness of oxygen therapy and helps assess whether hypoxemia is contributing to poor tissue perfusion.
💥Low O₂ saturation would indicate worsening pulmonary congestion and impaired gas exchange from heart failure, requiring rapid escalation of interventions.
🔷 Renal function labs (BUN, creatinine, GFR, electrolytes)
💥Serial monitoring of kidney function is critical to evaluate progression or improvement of AKI.
💥Rising creatinine and BUN indicate worsening renal impairment, while stabilizing or improving levels show recovery.
💥Electrolytes, especially potassium, must be closely followed to anticipate and prevent life-threatening complications.
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This question is from Examplify W4 NR325 NR330 Exam 1 which contains 57 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Medical-Surgical
- Answer Choices: 0