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?
A.
Provide a diet high in protein.
B.
Provide ibuprofen for retroperitoneal discomfort.
C.
Monitor intake and output hourly
D.
Encourage the client to consume at least 2 L of fluid daily
The correct answer and Explanation is :
The correct answer is C. Monitor intake and output hourly.
Explanation:
In the oliguric phase of acute kidney injury (AKI), the kidneys are unable to produce adequate urine, which leads to the retention of fluids and waste products in the body. Monitoring intake and output (I&O) is crucial in this phase for several reasons:
- Fluid Balance: Accurate I&O measurement helps assess the client’s fluid status. In AKI, the body may retain fluid, leading to complications such as edema and hypertension. By monitoring I&O, the nurse can identify trends in fluid retention or loss, allowing for timely interventions.
- Preventing Complications: Oliguria can result in the accumulation of toxins, electrolytes, and waste products, potentially leading to complications like metabolic acidosis or hyperkalemia. By closely monitoring I&O, the nurse can help manage fluid overload and prevent these dangerous conditions.
- Guiding Treatment Decisions: Monitoring I&O provides critical data that can inform treatment decisions, such as fluid restrictions, diuretics, or renal replacement therapy if necessary. It helps the healthcare team make informed decisions about managing the client’s condition.
- Client Safety: Regular I&O monitoring allows for prompt recognition of any changes in the client’s condition. If the client’s urine output decreases further or if they show signs of fluid overload, immediate interventions can be initiated.
Rationale for Other Options:
- A. Provide a diet high in protein: In the oliguric phase, protein intake should be moderated to reduce the burden of nitrogenous waste on the kidneys.
- B. Provide ibuprofen for retroperitoneal discomfort: Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can worsen kidney function and should be avoided in AKI.
- D. Encourage the client to consume at least 2 L of fluid daily: This is inappropriate during the oliguric phase, as fluid intake often needs to be restricted to prevent further fluid overload.
In summary, hourly monitoring of I&O is essential for managing a client in the oliguric phase of acute kidney injury, ensuring proper fluid management and preventing complications.