Nurse Think HEALTHCARE SYSTEM Name: J.R. Age: 47 years Health Care Provider: M. Starr MD Allergies: iodine MRN: 2557350128 Code Status: Full Code Review the information in the electronic health record. Which client assessment data is anticipated by the nurse? Select all that apply

A. The nurse anticipates tachycardia due to the metabolic disturbances and physiological stress associated with acute renal failure. Elevated potassium levels (6.8 mEq/L) can irritate the myocardium, leading to compensatory heart rate increases or dysrhythmias. Additionally, the initial hypovolemia from the motorcycle accident triggers sympathetic nervous system activation, maintaining a high heart rate. B. While renal disease can eventually lead to fluid retention, hypertension is not necessarily anticipated in the acute phase following severe hypovolemic shock. The client’s history of massive hemorrhage and hypovolemia from the accident suggests a risk for persistent hypotension or labile blood pressure. C. Confusion is a frequent assessment finding in clients with advancing renal impairment and elevated nitrogenous wastes. The accumulation of urea (BUN 25 mg/dL) and other toxins crosses the blood-brain barrier, resulting in uremic encephalopathy. Metabolic acidosis, which often accompanies a low GFR of 51 mL/min/1.73 m2, further depresses the central nervous system. D. Decreased urinary output is the hallmark clinical sign of AKI, reflecting a significant drop in renal perfusion and filtration capacity. With a GFR reduced to 51 mL/min/1.73 m2 and elevated creatinine of 2.0 mg/dL, the kidneys are unable to effectively excrete fluid. The client is likely in the oliguric phase, where the volume of urine produced is insufficient to maintain homeostasis. E. There is no evidence in the record to suggest oxygen requirements would be decreasing; in fact, they may increase. The presence of an elevated WBC (11,500 mm3) and the stress of a spinal cord injury (T8 severance) increase metabolic demands. Furthermore, fluid overload from AKI can lead to pulmonary edema, which would worsen rather than improve oxygenation status.