The nurse is caring for a client who is in the oliguric phase of acute kidney injury (AKI). During this phase of AKI, the nurse might anticipate which of the following findings?

Hyperkalemia

Urine output of 2000 mL in 24 hours

Tachycardia

Tenting of the skin

Answer and Explanation

The Correct Answer is A

Choice A reason: In the oliguric phase of AKI, kidney function is severely impaired, reducing potassium excretion. This leads to hyperkalemia, which disrupts cardiac electrical activity, potentially causing life-threatening arrhythmias or cardiac arrest. Elevated potassium levels are a hallmark of this phase due to decreased glomerular filtration rate and impaired tubular secretion.

Choice B reason: Urine output of 2000 mL in 24 hours indicates polyuria, characteristic of the recovery phase of AKI, not the oliguric phase, where output is typically less than 400 mL/day. High urine output suggests restored renal function, which is not expected in the oliguric phase, where kidneys fail to filter adequately.

Choice C reason: Tachycardia may occur in AKI due to fluid overload causing increased cardiac workload or electrolyte imbalances like hyperkalemia affecting heart rhythm. However, it is a secondary symptom and less specific than hyperkalemia, which directly results from impaired renal excretion and poses a more immediate risk to cardiac function.

Choice D reason: Tenting of the skin indicates dehydration, which may precede AKI but is not typical in the oliguric phase, where fluid retention is more common due to reduced urine output. Fluid overload leads to edema, not dehydration, making skin tenting an unlikely finding in this phase of AKI.

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Correct Answer is A

Explanation

Choice A reason: In ESRD, anuria means no urine output, so excess fluid accumulates in the body, increasing intravascular volume. This can cause hypertension, pulmonary edema, and respiratory distress. Educating the client about these risks emphasizes the importance of fluid restrictions to prevent life-threatening complications between dialysis sessions, addressing their frustration accurately.

Choice B reason: Advising increased fluid intake is incorrect for anuric ESRD patients, as their kidneys cannot excrete fluid. This would exacerbate fluid overload, leading to hypertension, heart failure, or pulmonary edema. Hydration is managed through dialysis, not increased oral intake, which could overwhelm the body’s limited fluid-handling capacity.

Choice C reason: Stating that fluid intake is unrestricted with dialysis is incorrect. Even with regular dialysis, excessive fluid intake between sessions can lead to overload, causing hypertension or pulmonary edema. Dialysis removes a limited amount of fluid per session, requiring strict restrictions to maintain safe fluid balance and prevent complications.

Choice D reason: While potassium and phosphorus restrictions are critical in ESRD to prevent hyperkalemia and hyperphosphatemia, the client’s question focuses on fluid restrictions. This response does not address fluid overload risks like hypertension or pulmonary edema, which are direct consequences of excessive fluid intake in anuric patients, making it irrelevant to the query.

A. Administer a bolus of IV normal saline as ordered B. Flush the peritoneal catheter with normal saline C. Assess the client for signs of infection D. Continue to monitor the color of the dialysate

Correct Answer is C

Explanation

Choice A reason: Administering IV normal saline addresses fluid volume deficits, not cloudy dialysate, which suggests peritonitis in CAPD. Saline does not treat infection or clarify drainage. Without addressing the potential infection, complications like sepsis or peritoneal membrane damage may occur, making this intervention irrelevant to the finding.

Choice B reason: Flushing the peritoneal catheter with saline risks introducing bacteria or dislodging clots, worsening potential infection. Cloudy dialysate indicates peritonitis, requiring assessment and likely antibiotics, not flushing. This action could compromise the catheter’s integrity and is not a standard intervention for suspected peritonitis in CAPD.

Choice C reason: Cloudy dialysate is a hallmark of peritonitis in CAPD, caused by bacterial infection. Assessing for fever, abdominal pain, or rebound tenderness confirms infection, enabling prompt antibiotic treatment. Early intervention prevents sepsis or peritoneal membrane scarring, which could necessitate dialysis modality change, making this the priority action.

Choice D reason: Continuing to monitor without assessing for infection delays treatment of potential peritonitis, a serious CAPD complication. Cloudy dialysate requires immediate evaluation, as untreated infection can lead to sepsis, peritoneal damage, or death. Passive monitoring risks patient safety, making this an inadequate response to a critical finding.

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The nurse is caring for a client who is in the oliguric phase of acute kidney injury (AKI). During this phase of AKI, the nurse might anticipate which of the following findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (CAPD). The nurse observes that the dialysate drainage fluid is cloudy. What is the priority intervention?

Correct Answer is C

Explanation

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