# A client with type 2 diabetes on metformin undergoes contrast-enhanced CT. Review the trend and answer each question. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=568333&lang=en > language: en > subject: Medication Administration > category: PPT ## Question A client with type 2 diabetes on metformin undergoes contrast-enhanced CT. Review the trend and answer each question. | Time | Data | | --- | --- | | Time 0 (pre-contrast) | creatinine: 1.4 mg/dL (124 µmol/L); eGFR: 48 mL/min/1.73 m²; urine output: 50 mL/hr; bp: 138/82; hr: 78; lactate: 1.1 mmol/L | | Time 6 hr | creatinine: 1.6 mg/dL (141 µmol/L); eGFR: 41 mL/min/1.73 m²; urine output: 35 mL/hr; bp: 128/76; hr: 84; lactate: 1.4 mmol/L | | Time 24 hr | creatinine: 1.9 mg/dL (168 µmol/L); eGFR: 34 mL/min/1.73 m²; urine output: 28 mL/hr; bp: 122/70; hr: 92; lactate: 1.8 mmol/L | | Time 48 hr | creatinine: 2.3 mg/dL (203 µmol/L); eGFR: 27 mL/min/1.73 m²; urine output: 22 mL/hr; bp: 118/68; hr: 98; lactate: 2.2 mmol/L | Q1. What is the most likely cause of the client's deteriorating renal function? Progression of pre-existing chronic kidney disease unrelated to contrast Metformin-induced acute tubular necrosis Contrast-induced acute kidney injury superimposed on chronic kidney disease Isolated volume depletion from pre-procedure fasting Q2. Which action is most appropriate regarding metformin at this time? Discontinue metformin permanently and document in the chart Continue to hold metformin and notify the provider of the renal decline Restart metformin at a reduced dose of 500 mg twice daily Resume metformin only if lactate returns to baseline Q3. What is the priority nursing intervention based on the trend? Escalate care by notifying the provider and preparing for possible hemodialysis Increase IV fluid rate to 200 mL/hr and reassess in 6 hours Administer an antiemetic for nausea and continue monitoring Obtain a urine culture to rule out infection ## Explanation The trend shows progressive renal decline with decreasing urine output, rising lactate, and tachycardia despite IV fluids. The most likely cause is contrast-induced acute kidney injury superimposed on CKD, not isolated volume depletion. Metformin must remain held, and the priority is to escalate care for worsening AKI and possible lactic acidosis. ## In-depth explanation Quick answer The correct answers reflect recognition of contrast-induced AKI with early signs of lactic acidosis, the need to hold metformin, and escalation of care. Why this is correct Creatinine rises from 1.4 to 2.3 mg/dL over 48 hours with falling urine output, rising lactate, and compensatory tachycardia. This pattern indicates acute kidney injury, most likely contrast-induced in the setting of pre-existing CKD, not simply dehydration. Clinical picture Contrast-induced AKI typically presents within 48-72 hours. Metformin is contraindicated when eGFR is below 30 mL/min/1.73 m² or during acute kidney injury due to risk of lactic acidosis. Rising lactate with declining renal function is an early warning sign. Memory hook Metformin + contrast + falling eGFR = hold metformin, monitor for lactic acidosis, escalate care. NCLEX decision rule Metformin should be withheld during acute kidney injury and for at least 48 hours after contrast if renal function deteriorates. Lactic acidosis is a medical emergency requiring immediate provider notification. Why the alternatives are wrong Volume depletion alone would typically improve with IV fluids, not worsen. Pre-existing CKD alone would not explain the acute rise. Restarting metformin or continuing current management would be unsafe. Sources 1NCSBN 2026 NCLEX-RN Test Plan 2DailyMed Metformin Hydrochloride ## Clinical scenario A 58-year-old client with type 2 diabetes, hypertension, and stage 3a chronic kidney disease (baseline creatinine 1.4 mg/dL [124 µmol/L], eGFR 48 mL/min/1.73 m²) is admitted for evaluation of abdominal pain. Metformin 1000 mg twice daily is held the morning of a contrast-enhanced CT with iohexol. IV normal saline is started at 100 mL/hr before the procedure. The client reports mild nausea but no vomiting after contrast administration. ## Key concepts - **Contrast-induced acute kidney injury** — An acute decline in renal function following intravascular contrast administration, typically defined as a ≥0.5 mg/dL or ≥25% increase in creatinine within 48-72 hours. - **Metformin-associated lactic acidosis** — A rare but life-threatening complication of metformin accumulation, characterized by elevated lactate (>5 mmol/L), metabolic acidosis, and often accompanied by renal impairment. - **eGFR** — Estimated glomerular filtration rate, a calculated measure of kidney function used to guide medication dosing and detect renal impairment. ## Related questions - [Before giving a scheduled dose of digoxin, the nurse obtains an apical pulse of 54/min in …](https://mymerci.kr/pages/nclex_q.php?qn_id=374883&lang=en) - [An older adult taking digoxin reports nausea, poor appetite, and yellow-green halos. 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