# A client with type 2 diabetes and severe chronic kidney disease has a stable eGFR of 25 mL/min/1.73 m2 and is scheduled for elective CT angiography with iodinated contrast. Current medications include metformin and as-needed ibuprofen. Which actions are appropriate? Select all that apply.

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> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A client with type 2 diabetes and severe chronic kidney disease has a stable eGFR of 25 mL/min/1.73 m2 and is scheduled for elective CT angiography with iodinated contrast. Current medications include metformin and as-needed ibuprofen. Which actions are appropriate? Select all that apply.

1

Notify the prescribing team about ibuprofen use and hold nonessential nephrotoxic medication around the study as directed

2

Give IV mannitol before contrast to force diuresis because this reliably prevents contrast-associated acute kidney injury

3

Administer prescribed isotonic IV fluid before and after contrast using a rate and duration adjusted for body size, cardiac function, and volume status

4

Continue metformin through the procedure because renal function does not affect the risk associated with metformin if acute kidney injury develops

5

Hold metformin at or before contrast administration and for 48 hours afterward, then restart only after renal function is reassessed and stable

6

Monitor renal function and urine output after exposure and promptly report oliguria or a clinically significant creatinine increase

## Explanation

With eGFR below 30 mL/min/1.73 m2, the team weighs the imaging benefit against kidney risk and uses individualized prevention. Avoiding nonessential nephrotoxins such as ibuprofen reduces additive risk (Choice 1). Isotonic volume expansion is the preferred prophylaxis when not contraindicated, but the rate and duration must account for heart failure and volume status rather than using one rigid regimen for every client (Choice 3). ACR guidance places this client in the category in which metformin is held at or before iodinated contrast and for 48 hours, then restarted after renal function is stable (Choice 5). Monitor for contrast-associated acute kidney injury with renal function and urine output rather than relying on an outdated 25% creatinine threshold alone (Choice 6). Mannitol does not reliably prevent injury and can worsen volume problems (Choice 2). Continuing metformin despite severe CKD is unsafe if acute kidney injury occurs and the drug accumulates (Choice 4).

## In-depth explanation

Clinical Judgment
The big-three CIN risks are CKD, diabetes, and dehydration — and the client in this scenario has all three. The nurse layers prevention: isotonic NS hydration + metformin hold + nephrotoxic drug hold + post-procedure SCr monitoring.

Memory Tip
CIN-AKI definition = SCr rise ≥ 0.3 mg/dL OR ≥ 25% within 24–72 hours. Hydration target = 1 mL/kg/hour for 6–12 hours pre and post. Metformin = hold at contrast and for 48 hours after.

KR vs US
In Korea NAC and bicarbonate were popular CIN prophylaxis options, but recent KDIGO and ACR guidelines emphasize isotonic crystalloid hydration as the only consistently effective intervention. NCLEX-RN reflects that shift: pick the IV NS hydration option, not mannitol or NAC alone.

## Clinical scenario

Clinical Practice Guide
KDIGO and ACR Manual on Contrast Media: hydrate at-risk clients with isotonic 0.9% NaCl, hold metformin and other nephrotoxins, use the lowest contrast volume possible, and consider alternative imaging when eGFR < 30. Highest-risk clients: CKD, diabetes, dehydration, heart failure, multiple myeloma, age over 75.

Caution
Common NCLEX traps: continuing metformin on the day of contrast, giving mannitol or loop diuretics for prophylaxis, and ignoring NSAIDs. Remember: a SCr rise of just 0.3 mg/dL is enough to call it CIN — monitor closely for 48–72 hours.

## Key concepts

- **Contrast-Induced Nephropathy (CI-AKI)** — Acute kidney injury within 24 to 72 hours of iodinated contrast administration, defined by a serum creatinine rise of 0.3 mg/dL or 25 percent over baseline. Risk factors: chronic kidney disease, diabetes, dehydration, heart failure, age over 75, multiple myeloma, and concurrent nephrotoxic drugs. Most cases resolve in 7 to 14 days. NCLEX exam tip: prevention is volume expansion with isotonic crystalloid plus holding nephrotoxins.
- **Metformin Hold for Contrast** — Metformin is not nephrotoxic, but if acute kidney injury develops it is no longer cleared and accumulates, causing lactic acidosis. Practice: hold metformin at the time of contrast and for 48 hours after, then resume only after renal function is reassessed. NCLEX exam tip: any client on metformin who is going for iodinated contrast or surgery requires a metformin hold.
- **Isotonic Crystalloid Hydration** — Volume expansion with 0.9% sodium chloride or isotonic sodium bicarbonate at 1 mL/kg per hour for 6 to 12 hours before and after iodinated contrast in clients at risk of CIN. Improves renal perfusion, dilutes intratubular contrast, and reduces medullary ischemia. NCLEX exam tip: this is the only intervention with consistent CIN-prevention evidence — diuretics, dopamine, and N-acetylcysteine are not first-line.

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