A nurse is caring for a 40-year-old client admitted with acute post-streptococcal glomerulonephritis following a recent throat infection. The client presents with periorbital edema, hypertension (160/95 mmHg), oliguria (urine output 200 mL in 8 hours), and tea-colored urine. Laboratory results show proteinuria (3+ protein), hematuria, elevated BUN (45 mg/dL), and creatinine (2.1 mg/dL). The client reports fatigue and mild shortness of breath. Which nursing intervention should be the highest priority?
A 28-year-old client is admitted with acute post-streptococcal glomerulonephritis following a recent throat infection. The client presents with periorbital edema, hypertension (160/95 mmHg), oliguria (urine output 200 mL in 8 hours), and tea-colored urine. Laboratory results show proteinuria (3+ protein), hematuria, elevated BUN (45 mg/dL), and creatinine (2.1 mg/dL). The client reports fatigue and mild shortness of breath.
1Encourage increased fluid intake to promote kidney function
2Administer prescribed diuretics to reduce edema
3Monitor blood pressure and implement hypertension management✓ 정답
4Provide high-protein diet to replace protein losses
해설
Hypertension management is the highest priority to prevent life-threatening complications like cerebral edema or seizures in acute glomerulonephritis. Other interventions are important but secondary to blood pressure control.
This client is presenting with classic manifestations of acute post-streptococcal glomerulonephritis (PSGN), an immune-complex mediated inflammation of the glomeruli following a group A beta-hemolytic streptococcal infection. The clinical picture—hypertension, oliguria, edema, and elevated BUN and creatinine—indicates an acute decline in the glomerular filtration rate (GFR). In this scenario, the nurse must prioritize interventions using the ABC (Airway, Breathing, Circulation) framework and the nursing process, focusing on the most life-threatening complication.
Analysis of the Correct Answer (Option 3)
Monitoring blood pressure and implementing hypertension management is the highest priority. The client’s blood pressure is significantly elevated at 160/95 mmHg. In the context of PSGN, hypertension results from sodium and water retention due to impaired renal excretion, leading to hypervolemia. Uncontrolled, severe hypertension poses an immediate risk of hypertensive encephalopathy, seizures, and further cardiac strain. The client’s report of mild shortness of breath is a critical cue; combined with hypertension and fluid overload, this signals a high risk for developing acute pulmonary edema, a life-threatening complication of PSGN. As noted in the provided case report, PSGN can rarely result in life-threatening complications including acute pulmonary edema [1]. Addressing the elevated blood pressure directly mitigates this imminent risk to the client’s airway and breathing.
Critical Analysis of Incorrect Options
Option 1: Encourage increased fluid intake to promote kidney function. This intervention is contraindicated. The client is in a state of hypervolemia, evidenced by hypertension, periorbital edema, and oliguria (urine output of only 200 mL in 8 hours). The kidneys are unable to effectively filter and excrete fluid. Increasing intake would worsen fluid overload, exacerbate hypertension, and directly increase the risk of pulmonary edema and heart failure. Management of PSGN in the oliguric phase focuses on fluid restriction, typically calculated as insensible losses plus the previous day's urine output.
Option 2: Administer prescribed diuretics to reduce edema. While administering a prescribed diuretic is an important intervention to manage fluid overload and hypertension, it is not the highest priority nursing action. The nurse must first assess the client’s response to therapy and the current status of the complication being treated. Monitoring blood pressure is a prerequisite assessment that guides the safe administration and evaluation of antihypertensive and diuretic therapy. In the hierarchy of the nursing process, assessment precedes implementation. Therefore, the priority is to monitor and manage the blood pressure, which encompasses assessing the need for and response to a diuretic.
Option 4: Provide high-protein diet to replace protein losses. This intervention is not a priority and is potentially harmful in the acute phase. The significant proteinuria (3+ protein) is due to a damaged glomerular basement membrane allowing protein to leak into the urine, not a nutritional deficiency. Providing a high-protein diet would increase the load of nitrogenous waste products that the already compromised kidneys must excrete, potentially worsening azotemia, as reflected in the elevated BUN (45 mg/dL) and creatinine (2.1 mg/dL). The dietary focus during the acute oliguric phase is typically on restricting protein, sodium, and potassium while ensuring adequate caloric intake.
Pathophysiological Rationale and Clinical Integration
The underlying pathology in PSGN involves the deposition of antigen-antibody complexes within the glomeruli, activating the complement system and causing diffuse inflammation. This leads to a reduction in GFR. The kidneys' inability to filter blood effectively explains all the client’s key findings. The retention of sodium and water directly causes hypervolemia, manifesting as hypertension and edema. The inflamed glomerular capillaries allow red blood cells and protein to pass into the urine, resulting in hematuria (tea-colored urine) and proteinuria [1]. The accumulation of metabolic waste products like urea and creatinine leads to elevated BUN and creatinine levels. The immediate threat to life stems from the cardiovascular consequences of this fluid and pressure overload, making blood pressure monitoring and control the nurse's unequivocal priority.
References (research sources)
[1]
Post-streptococcal Glomerulonephritis Presenting With Acute Pulmonary Edema and Critical Hyperkalemia: A Rare Pediatric Case Report From Yemen.Case reportMohamed AAA, Ayish MKM, Muafa HM. (2026) · DOI: 10.1177/11795476261444444
Managing Hypertension in Acute PSGNPrioritizing Circulation to Prevent Life-Threatening Complications
In acute post-streptococcal glomerulonephritis, hypertension stems from sodium and water retention due to a falling GFR. The immediate priority is blood pressure control because severe hypertension (160/95 mmHg) can rapidly progress to hypertensive encephalopathy or acute pulmonary edema.
Assess for cues of impending crisis: dyspnea, crackles, headache, or vision changes. Implement prescribed antihypertensives and fluid restriction strictly. Monitor urine output hourly; oliguria (<400 mL/24hr) signals worsening fluid overload.
Caution
Do not encourage increased fluids or a high-protein diet. Fluids worsen hypervolemia; protein loads increase renal workload and azotemia. Diuretics are adjunctive but do not replace direct BP management as the first priority.
Acute Post-Streptococcal Glomerulonephritis (APSGN) — An immune-mediated inflammation of the glomeruli following infection with nephritogenic strains of group A beta-hemolytic streptococcus, characterized by hematuria, proteinuria, edema, hypertension, and oliguria.
Oliguria — Urine output less than 400 mL per day or less than 0.5 mL/kg/hour, indicating significantly reduced kidney function and fluid retention.
Fluid Volume Excess — A state of hypervolemia caused by sodium and water retention due to impaired glomerular filtration, leading to hypertension, edema, and risk of pulmonary congestion.
Pulmonary Edema — Accumulation of fluid in the lung interstitium and alveoli, often a life-threatening complication of severe fluid overload and hypertension in renal failure.