A nurse is teaching a client who has acute kidney injury (AKI) about the oliguric phase. Which of the following information should the nurse include in the teaching?

The glomerular filtration rate (GFR) recovers.

Urine output is less than 400 mL per 24 hours.

BUN and creatinine levels decrease.

Renal function is reestablished.

Answer and Explanation

The Correct Answer is B

Choice A reason: The GFR does not recover during the oliguric phase; instead, it is typically reduced, reflecting impaired kidney function.

Choice B reason: Urine output of less than 400 mL per 24 hours is characteristic of the oliguric phase of AKI. This phase can last from 1 to 7 days after kidney injury and is a crucial time for monitoring and managing the patient's fluid and electrolyte balance.

Choice C reason: BUN and creatinine levels do not decrease during the oliguric phase. They usually increase due to reduced kidney function and the inability to excrete these waste products.

Choice D reason: Renal function is not reestablished during the oliguric phase. This phase is part of the course of AKI where renal function is at its lowest, and recovery has not yet begun.

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Correct Answer is A

Explanation

Choice A reason:Testing the drainage for the halo sign is the first action the nurse should take, as clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal fluid (CSF) leak, which contains glucose.

Choice B reason:Asking the client to blow his nose could potentially increase the risk of infection or worsen a CSF leak and is not recommended as a first action.

Choice C reason:While notifying the physician is important, it should be done after confirming whether the drainage is CSF, which would require immediate medical intervention.

Choice D reason:Suctioning the nostril is not the first action to take, as it could potentially disrupt the site of the leak and is not diagnostic of a CSF leak.

A. Tachypnea B. Hypotension C. Decreased level of consciousness D. Bilateral weakness of extremities

Correct Answer is C

Explanation

Choice A: Tachypnea Tachypnea, or rapid breathing, is not typically a direct sign of increased ICP. While it can be associated with various medical conditions, it is not specifically indicative of increased ICP. However, it’s important to note that breathing patterns can change with advanced ICP changes, but these are usually characterized by irregularities rather than just increased rate. Increased intracranial pressure (ICP) is a critical condition that can occur after a traumatic brain injury (TBI). It results from the brain tissue’s response to injury, leading to swelling or bleeding within the skull. The skull is a rigid structure, so any increase in content, such as blood or edema, can lead to an increase in pressure.

Choice B: Hypotension Hypotension, or low blood pressure, is generally not associated with increased ICP. In fact, one of the signs of increased ICP is Cushing’s triad, which includes hypertension (high blood pressure), bradycardia (slow heart rate), and irregular respirations. Therefore, hypotension would not be a typical manifestation of increased ICP.

Choice C: Decreased level of consciousness A decreased level of consciousness is a hallmark sign of increased ICP. As pressure within the skull increases, it can lead to compression of the brain tissue and disruption of cerebral blood flow. This can manifest as changes in alertness, drowsiness, confusion, and in severe cases, loss of consciousness1. when monitoring a client who has sustained a TBI, the nurse should be vigilant for signs of increased ICP, with a decreased level of consciousness being a primary indicator. Other signs may include headache, nausea, vomiting, and changes in pupil size or reactivity. It is crucial to identify and treat increased ICP promptly to prevent further brain injury and potential long-term consequences.

Choice D: Bilateral weakness of extremities While bilateral weakness can be a sign of neurological damage, it is not specific to increased ICP. Increased ICP is more likely to cause global effects on consciousness and brain function rather than isolated weakness in limbs unless there is focal brain injury causing raised ICP.

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A nurse is teaching a client who has acute kidney injury (AKI) about the oliguric phase. Which of the following information should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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