A nurse is reinforcing teaching with a client about the oliguric phase of acute kidney injury. Which of the following information should the nurse include in the teaching?

The oliguric phase lasts for 2 days.

The client's urine output is less than 400 mL per 24 hours.

The oliguric phase begins within 1 month of the injury.

The client's BUN and creatinine decreases during this phase.

Answer and Explanation

The Correct Answer is B

A.   The oliguric phase of AKI typically lasts longer than 2 days. It can extend from several days to weeks, depending on the underlying cause and the response to treatment.
B.   During the oliguric phase of AKI, urine output is significantly reduced. Typically, urine output is less than 400 mL per day, but it can vary widely based on the severity of kidney injury and individual factors.
C.   The oliguric phase of AKI usually begins within a few days to a week after the initial injury. It is characterized by a sudden decrease in urine output and may be accompanied by electrolyte imbalances and fluid overload.
D.   During the oliguric phase of AKI, there is typically a buildup of waste products such as blood urea nitrogen (BUN) and creatinine in the blood. These levels rise because the kidneys are unable to effectively filter and excrete waste products. Therefore, BUN and creatinine levels usually increase during the oliguric phase.

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Correct Answer is B

Explanation

A. Stiffness in the lower extremities can occur due to lack of movement and muscle disuse. Prolonged immobility leads to muscle atrophy and contractures, causing stiffness and reduced range of motion. This is a common complication seen in clients who are bedridden or have limited mobility.
B. A reddened area over the sacrum indicates a potential pressure injury or pressure ulcer. Immobility increases the risk of pressure ulcers due to prolonged pressure on bony prominences, such as the sacrum. Regular repositioning and pressure relief strategies are essential to prevent skin breakdown in immobile clients.
C. Difficulty hearing certain types of sounds is not typically associated with immobility. It may be related to age-related changes in hearing or other auditory issues but is not a direct complication of immobility.
D. Difficulty moving the upper extremities can occur due to muscle weakness or disuse atrophy, which can result from immobility. However, it is less common compared to stiffness and difficulty in the lower extremities because upper extremities are often more frequently moved or exercised even in bedridden clients.

A. Provide mouth care. B. Auscultate lung fields. C. Position the client so that the lung area to be drained is above the client's trachea. D. Cup hands and tap on the client's chest repeatedly.

Correct Answer is B

Explanation

A. Mouth care is an important aspect of overall care, but it is not directly related to chest percussion, vibration, and postural drainage. It can be done before or after these procedures as needed for client comfort and oral hygiene.
B. Auscultating the lung fields is a crucial step before initiating chest percussion, vibration, and postural drainage. It helps the nurse assess the current status of lung sounds, identify areas of congestion or consolidation, and determine the appropriate areas for percussion and drainage.
C. Positioning the client correctly is essential to facilitate effective drainage. By positioning the lung area to be drained above the trachea, gravity assists in moving secretions towards the larger airways for removal.
D. Chest percussion involves rhythmically tapping the chest wall with cupped hands to loosen and mobilize secretions in the lungs. This action helps to facilitate drainage during postural drainage.

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A nurse is reinforcing teaching with a client about the oliguric phase of acute kidney injury. Which of the following information should the nurse include in the teaching?

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