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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Close the curtains around the client’s bed.
Closing the curtains around the client's bed is a practical way to maintain the client's privacy during a bed bath. This action provides a visual barrier, ensuring that the client is shielded from the view of others in the room.
B. Close the door of the client’s room.
Closing the door is another way to enhance privacy, but it may not be as feasible in all situations. Closing the curtains provides immediate visual privacy without necessarily closing off the entire room.
C. Ask family members to leave the room.
This option is appropriate if family members are present and their presence is not essential for the bed bath. Asking them to step out temporarily can enhance the client's privacy.
D. Use a blanket to cover the client.
While using a blanket is a way to cover and provide modesty during the bed bath, closing the curtains is a more direct measure to maintain visual privacy. Blankets can be used as needed during the bed bath process.
Correct Answer is D
Explanation
A. “I don’t take naps throughout the day.”
This statement suggests that the client avoids daytime napping, which is generally a positive sleep habit. Excessive daytime napping can interfere with nighttime sleep.
B. “I go to bed and get up at the same times each day.”
Maintaining a consistent sleep schedule is a key component of good sleep hygiene. Going to bed and waking up at the same times helps regulate the body's internal clock.
C. “I have a small snack and take a bath before going to bed each day.”
Having a light snack and engaging in a relaxing activity like a bath before bedtime can contribute to a more conducive sleep environment. However, the type and timing of the snack should be considered.
D. “I watch television until I fall asleep at night.”
This statement may indicate a need for further instruction. Watching television right before bedtime, especially until falling asleep, can be counterproductive to good sleep hygiene due to the stimulating effects of the screen's blue light.
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