A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury (AKI). Which of the following findings should the nurse identify as indicating an increased risk of AKI?
Magnesium 2.5 mEq/L
Serum osmolality 290 mOsm/kg H2O
Blood urea nitrogen (BUN) 20 mg/dL
Serum creatinine 1.8 mg/dL
The Correct Answer is D
Choice A Reason: This is incorrect because magnesium 2.5 mEq/L is a normal value and does not indicate an increased risk of AKI. Magnesium is an electrolyte that plays a role in muscle and nerve function, blood pressure regulation, and energy production. The normal range for magnesium is 1.5 to 2.5 mEq/L.
Choice B Reason: This is incorrect because serum osmolality 290 mOsm/kg H2O is a normal value and does not indicate an increased risk of AKI. Serum osmolality is a measure of the concentration of solutes in the blood, such as sodium, glucose, and urea. The normal range for serum osmolality is 275 to 295 mOsm/kg H2O.
Choice C Reason: This is incorrect because blood urea nitrogen (BUN) 20 mg/dL is a normal value and does not indicate an increased risk of AKI. BUN is a measure of the amount of urea, a waste product of protein metabolism, in the blood. The normal range for BUN is 7 to 20 mg/dL.
Choice D Reason: This is correct because serum creatinine 1.8 mg/dL is an elevated value and indicates an increased risk of AKI. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. The normal range for serum creatinine is 0.6 to 1.2 mg/dL for women and 0.7 to 1.3 mg/dL for men. An increase in serum creatinine indicates a decrease in kidney function and glomerular filtration rate (GFR).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This choice is incorrect because administering a vasodilator medication may lower the blood pressure and worsen the cerebral perfusion. A vasodilator medication is a drug that relaxes the blood vessels and reduces the resistance to blood flow. It may be used for clients who have hypertension, angina, or heart failure, but it does not help to reduce the intracranial pressure (ICP).
Choice B Reason: This choice is correct because elevating the head of the bed to 30° may help to improve the venous drainage and decrease the ICP. ICP is the pressure exerted by the brain tissue, cerebrospinal fluid (CSF), and blood within the cranial cavity. A normal ICP range is 5 to 15 mm Hg, and an elevated ICP (>20 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, positioning the client in a semi-Fowler's position (30° angle) or high- Fowler's position (60° to 90° angle) can facilitate breathing and prevent further complications.
Choice C Reason: This choice is incorrect because applying a cold compress to the forehead may cause vasoconstriction and increase the ICP. A cold compress is a device that applies cold temperature to a body part to reduce inflammation, pain, or swelling. It may be used for clients who have headaches, sprains, or bruises, but it does not help to reduce the ICP.
Choice D Reason: This choice is incorrect because decreasing the oxygen flow rate may cause hypoxia and worsen the cerebral ischemia. Hypoxia is a condition in which the body or a part of it does not receive enough oxygen. It may cause symptoms such as confusion, agitation, or cyanosis. Therefore, providing adequate oxygenation and ventilation is essential to maintain the brain function and prevent further damage.

Correct Answer is D
Explanation
Choice A Reason: Cause of the burn is not the nurse's priority when assessing the severity of the client's burns. The cause of the burn may indicate the type and duration of exposure, such as thermal, chemical, electrical, or radiation, which can affect the depth and extent of injury. However, these factors are secondary to ensuring adequate oxygenation and ventilation.
Choice B Reason: Age of the client is not the nurse's priority when assessing the severity of the client's burns. The age of the client may influence the response to burn injury, such as healing time, infection risk, and fluid requirements.
However, these factors are secondary to ensuring adequate oxygenation and ventilation.
Choice C Reason: Associated medical history is not the nurse's priority when assessing the severity of the client's burns. The associated medical history may affect the outcome and prognosis of burn injury, such as pre-existing conditions, medications, or allergies. However, these factors are secondary to ensuring adequate oxygenation and ventilation.
Choice D Reason: Location of the burn is the nurse's priority when assessing the severity of the client's burns. The location of the burn can indicate the potential for life-threatening complications, such as airway obstruction, inhalation injury, or impaired circulation. The nurse should assess for signs and symptoms of respiratory distress, such as stridor, wheezes, or cyanosis, and prepare for endotracheal intubation if needed. The nurse should also monitor for signs and symptoms of compartment syndrome, such as pain, pallor, paresthesia, pulselessness, or paralysis, and report any findings to the provider. The location of the burn can also affect the functional and cosmetic outcomes, such as vision loss, facial disfigurement, or joint contractures. The nurse should provide appropriate wound care, pain management, and rehabilitation as prescribed. Assessing for location of burn is essential to prevent further injury and preserve vital functions.
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