A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?
Provide a diet high in protein.
Provide ibuprofen for retroperitoneal discomfort.
Monitor intake and output hourly
Encourage the client to consume at least 2 L of fluid daily
The Correct Answer is C
A. Provide a diet high in protein.
During the oliguric phase of acute kidney injury (AKI), there is a risk of electrolyte imbalances, including elevated levels of blood urea nitrogen (BUN) and creatinine. Restricting protein intake is often recommended during this phase to manage azotemia and prevent the accumulation of waste products that the kidneys may struggle to excrete.
B. Provide ibuprofen for retroperitoneal discomfort.
Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in AKI. They can further compromise renal function and may contribute to acute tubular necrosis. NSAIDs can also affect renal blood flow, leading to worsening kidney function.
C. Monitor intake and output hourly.
Monitoring intake and output (I&O) is a critical nursing intervention during the oliguric phase of AKI. Hourly monitoring helps assess renal function, fluid balance, and the effectiveness of interventions. It allows for early detection of changes that may require prompt intervention.
D. Encourage the client to consume at least 2 L of fluid daily.
In the oliguric phase of AKI, fluid intake is often restricted to prevent fluid overload. Encouraging excessive fluid intake may contribute to fluid retention and worsen the oliguria. Fluid management is carefully regulated based on the individual client's needs and renal function.
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Related Questions
Correct Answer is B
Explanation
A. Ensure the rope knots are away from the pulleys.
While ensuring that rope knots are away from the pulleys is a general principle in traction care to maintain proper functioning, it is not directly related to the specific positioning of the child's feet in Buck's traction.
B. Ensure the child’s feet are against the footboard.
This statement is correct. Ensuring that the child's feet are against the footboard helps maintain proper hip alignment and prevent complications such as contractures. It is an important aspect of care when managing Legg-Calve-Perthes disease in Buck's traction.
C. Apply antibiotic ointment to the pin sites daily.
This action is not applicable to Buck's traction. Buck's traction involves the use of a boot or splint, and it does not include pins or pin sites. The use of antibiotic ointment for pin sites is more relevant in the context of skeletal traction.
D. Reduce the child’s fluid intake.
There is no indication to reduce the child's fluid intake specifically in the context of Buck's traction. Adequate hydration is generally important for overall health, and fluid restriction is not a standard practice for managing Legg-Calve-Perthes disease in Buck's traction.
Correct Answer is C
Explanation
A. Skeletal traction
Skeletal traction involves the use of pins or wires that are surgically inserted directly into the bone. It is a more invasive form of traction commonly used during or after surgery. Skeletal traction provides a strong and direct pull on the bones, allowing for better alignment and immobilization.
B. Pelvic sling
A pelvic sling is not a specific type of traction. It may refer to a supportive device or garment that helps stabilize the pelvis. While it can provide support, it does not apply the same type of traction force as Buck's traction or skeletal traction.
C. Buck’s traction
Buck's traction is a type of skin traction commonly used as a temporary measure to immobilize and align fractured bones, particularly in the lower extremities. It involves the application of a boot or a splint to the affected leg, with traction applied through a system of weights and pulleys. Buck's traction is often used before hip surgery.
D. Russell’s traction
Russell's traction involves the application of traction to the lower leg using a splint and bandages. It is often used for fractures of the femur. While it is a form of traction, it is not commonly used for hip fractures.
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