A client is in the oliguric phase of acute kidney injury (AKI) which was caused by massive tissue trauma. The nurse notes peaked T-waves and a widened QRS complex on the cardiac monitor. What is the first action the nurse should take?
Check the client's most recent potassium level
Administer a bolus of 1,000 mL of normal saline
Administer potassium chloride intravenously (IV)
Administer sodium polystyrene sulfonate (Kayexalate)
The Correct Answer is A
A. Peaked T-waves and a widened QRS complex on an ECG are often signs of hyperkalemia, which is an elevated potassium level in the blood. This can be a serious complication of acute kidney injury (AKI), especially in the oliguric phase when the kidneys are unable to effectively excrete potassium.A
B. While fluid management is important in AKI, administering a bolus of normal saline is not the first priority in the presence of suspected hyperkalemia. The primary concern is to address the electrolyte imbalance.
C. Administering potassium chloride would worsen hyperkalemia and should be avoided.
D. Kayexalate is a medication used to treat hyperkalemia by exchanging sodium ions for potassium ions in the gastrointestinal tract. However, checking the potassium level is the first step in confirming the diagnosis and determining the appropriate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The ACTH stimulation test measures the adrenal glands' response to ACTH, not the kidneys.
B. In Addison’s disease, the adrenal glands are damaged and unable to produce sufficient cortisol even when stimulated by ACTH. Therefore, plasma cortisol levels will not rise significantly in response to
ACTH administration in individuals with Addison’s disease.
C. The ACTH stimulation test involves administering ACTH via injection, not orally.
D. ACTH (adrenocorticotropic hormone) is produced by the pituitary gland and stimulates the adrenal glands to produce cortisol. The ACTH stimulation test assesses how well the adrenal glands respond to ACTH, which is crucial for diagnosing conditions like Addison’s disease, where the adrenal glands do not respond appropriately.
Correct Answer is B
Explanation
A. Gallstones are formed in the gallbladder and are not directly related to PKD.
B. Polycystic kidney disease (PKD) is a genetic disorder characterized by the growth of numerous cysts in the kidneys. These cysts can obstruct the flow of urine, making it easier for bacteria to grow and cause a urinary tract infection (UTI).
C. Hypotension is low blood pressure. While PKD can lead to kidney failure, which can cause hypotension, it is not a common complication.
D. Osteoporosis is a condition characterized by weak bones. While PKD can lead to kidney failure, which can affect calcium metabolism and contribute to osteoporosis, it is not a common complication.
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