A nurse is responsible for screening client’s history for risk factors for possible complications.
Vital signs
BP 188/93
P 80
A nurse is correlating data documented in a client's medical history. The nurse should recognize that which client data indicates risk factors for acute kidney injury? (Select all that apply.)
low serum albumin
Renal Calculi
Hypertension
Hypovolemia
ineffective wound healing
Correct Answer : B,C,D
A. Low serum albumin: While low albumin indicates poor nutrition or liver disease, it's not a direct cause of AKI.
B. Renal Calculi: Can cause obstruction in the urinary tract, leading to post-renal AKI.
C. Hypertension: Chronic high BP damages renal vasculature, increasing AKI risk.
D. Hypovolemia: Decreased perfusion leads to prerenal AKI.
E. Ineffective wound healing: Indicates poor nutrition or infection, but is not a primary AKI risk factor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Draw blood for a CBC: Important, but not the priority.
B. Inspect the mouth for signs of inhalation injuries: Airway assessment is always the priority in facial/chest burns due to the risk of inhalation injury and impending airway compromise.
C. Administer intravenous pain medication: Important, but airway always comes first.
D. Insert an indwelling urinary catheter: Urine output monitoring is important for fluid resuscitation but follows airway stabilization.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Critical to assess: A. Airway patency and signs of inhalation injury
Clients in enclosed-space fires are at high risk for inhalation injury, which can lead to airway edema and obstruction. This is the first priority.
Critical assessment finding: C. Singed nasal hairs and soot around the nares
These are hallmark signs of possible inhalation injury and may indicate airway compromise even before symptoms become severe.
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