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

Answer and Explanation

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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Correct Answer is B

Explanation

A. “I wish I didn’t have to attach the electrodes to my skin.”

This statement reflects a common sentiment. Attaching electrodes to the skin is part of using TENS, and it's a non-invasive procedure where electrodes are placed on the skin surface to deliver electrical impulses for pain relief.

B. “It’s unfortunate that I have to be in the hospital for this treatment.”

This statement indicates a need for further teaching. TENS is typically an outpatient treatment, and individuals can use TENS units at home after receiving appropriate instructions and training. It does not require being in the hospital.

C. “I’ll need to shave the hair off the skin where I place the electrodes.”

This statement is accurate. To ensure proper contact and effectiveness, it is often recommended to shave or trim the hair in the area where the electrodes will be placed.

D. “I hope I don’t have to take as many pain pills.”

This statement reflects an understanding of the potential benefits of TENS. TENS is used as an adjunct therapy to help manage pain, and one of its goals may be to reduce the need for pain medications.

A. I will rest for at least 30 minutes before eating. B. I will drink plenty of beverages with my meals. C. I will eat five or six small meals each day? D. I will increase my intake of protein.

Correct Answer is B

Explanation

A. "I will rest for at least 30 minutes before eating."
This statement is appropriate. Resting before meals can help conserve energy and reduce dyspnea (shortness of breath) during eating for individuals with COPD.

B. "I will drink plenty of beverages with my meals."
This statement indicates a need for further teaching. Excessive fluid intake during meals can contribute to feelings of fullness and increase the risk of bloating, making it more difficult for the client with COPD to breathe comfortably.

C. "I will eat five or six small meals each day."
This statement is appropriate. Eating smaller, more frequent meals can help prevent overdistension of the stomach and reduce the feeling of fullness, making it easier for the client to breathe.

D. "I will increase my intake of protein."
This statement is appropriate. Adequate protein intake is important for individuals with COPD to support respiratory muscle function and overall nutritional status.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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