This is a renal NCLEX practice question about the stages of acute kidney injury. This question provides a scenario about a patient with AKI. As the nurse, you must determine what stage of AKI this patient is in along with the complications and signs/symptoms that may present in this stage.
This question is one of the many questions we will be practicing in our new series called “Weekly NCLEX Question”.
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Renal NCLEX Question on Acute Kidney Injury
A 36 year old male patient is diagnosed with acute kidney injury. The patient’s 24 hour urinary output is 4.5 liters. Based on this stage of AKI, what complications and assessment findings may present in this patient? Select all that apply:
A. Water intoxication
C. Low urine specific gravity
E. GFR >90 mL/min
F. Normal BUN and Creatinine level
G. Profound confusion due to azotemia
After reading the scenario, you should say to yourself, “what stage of acute kidney injury is this patient in and what is a normal 24 hour urine output in an adult?”
Then start eliminating options that do not present in this stage. Tip: Each stage has specific complications and signs/symptoms. Therefore, once you determine the stage you can easily eliminate the incorrect options.
Normal 24-hour urine output in an adult? 1-2 liters/day
How many stages of AKI are there? FOUR
Let’s dissect each stage because this will help us eliminate options.
- Initiation: a cause creates injury to the kidney and then signs and symptoms start to appear which leads to the next stage. This stage lasts a few hours to several days.
*It is safe to say this patient isn’t in the initiation stage. So, let’s move on to the next stage…..
- Oliguric: *some patients skip this stage and go straight into the diuresis stage
Hallmark of this stage: Urine output will be less than 400 ml/day
Glomerulus is NOT filtering the blood properly: DECREASED GFR which will lead to the following signs and symptoms you will see in the patient:
- Increased BUN and CREATININE: neuro changes ex: confusion due to azotemia, itching
- Increased Potassium (hyperkalemia) >5.1 meq/L: due to the nephrons decreased ability to excrete potassium. It builds up in the blood and the patient is at risk for a significant cardiac event
- Increased fluid in the body: edema, at risk for fluid overload (pulmonary, cardiac issues: hypertension) because the glomerulus is unable to remove excessive water from the blood.
- Metabolic acidosis: blood pH less than 7.35 due to the decrease in the excretion of hydrogen ions by the nephrons. Patient may be confused and have kussmaul breathing. This is deep and rapid breathing. The respiratory system is trying to compensate by blowing off carbon dioxide (which is an acid) to help increase the blood’s pH.
- Mild hyponatremia (can be normal): diluted from fluid overload and decreased ability of the nephron to reabsorb sodium
- High phosphorus and low calcium: nephron can’t regulate phosphate and calcium levels
- Highly concentrated urine: high urine specific gravity >1.020
How long does this stage last? A week to 2 weeks. It is important this stage is as short as possible because the longer the patient stays in this stage the more of a risk of long term damage to the kidneys.
*Based on this knowledge, it is safe to say this patient is NOT in the oliguric stage. Remember the patient’s urinary output in this scenario is 4.5 liter/day….must be 400 ml or less/day to be oliguric. Therefore, we can eliminate the following options: A and G
Hallmark of this stage: urinary output will be 3-6 liters/day
Why? The nephrons can’t concentrate urine (so it can’t regulate water and electrolyte levels yet) but they can NOW filter out waste.
So, what will be found highly concentrated in the urine? WASTE…specifically urea.
This will cause OSMOTIC DIURESIS.
The patient will be voiding out an excessive amount of urine (3-6 Liters/day) due to osmotic diuresis. This occurs from the high amounts of urea in the newly filtered filtrate.
NURSING Role: strict I and O’s, daily weights, monitor for signs and symptoms of dehydration, HYPOVOLEMIA, hypotension.
As the GFR improves (still abnormal) this will allow the BUN and CREAT to decrease but the levels will still be abnormal. Therefore, the patient’s azotemia will start resolving, and the patient will become more alert and oriented.
Other signs and symptoms of this stage:
Hypokalemia: per MD order may give supplements and IV fluids to prevent dehydration
Urine diluted: low urine specific gravity <1.020
Lasts a week to 3 weeks
*Based on this knowledge, we know the patient is definitely in the diuresis stage of AKI. Therefore, the options we can eliminate are: F and E
The patient’s GFR will be increasing but it will still be abnormal. A normal GFR is >90 mL/min. In addition, azotemia will be resolving so the patient will start to become more alert and oriented.
Why is the patient not in recovery stage: In this stage the GFR has returned to normal and the kidneys start to function normally.
Urine output returns to normal along with BUN and creatinine, and electrolytes level. Therefore, the body is able to maintain these values.
This stage can last a year or more, and it depends on the amount of damage done to the kidney and the patient’s age.
Some patients are unable to progress to the recovery phase and instead develop Chronic Kidney Disease.
Answers to this question: B, C, D
- “Acute Kidney Injury, Chronic Kidney Disease Each A Risk Of The Other.” National Institutes of Health (NIH). Web. 10 July 2017.